Every finding on record at Center Point Health Care and Rehab

Based on observation, interviews, and record review, the facility failed to ensure residents who required assistance to carry out activities of daily living (ADLs) received the necessary services to maintain oral hygiene for 1 (#1) of 3 residents reviewed for ADLs. Findings: Review of the facility's policy titled Oral Care, dated 10/2020, revealed the following, in part:Policy: It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Deposits (Accretions) on Teeth, Disorder of Teeth and Supporting Structures, and Need for Assistance with Personal Care. Review of Resident #1's Quarterly MDS with an ARD of 06/21/2026 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she was dependent on staff for oral hygiene care needs. Review of Resident #1's current Care Plan revealed the following:Focus: The resident has an ADL self-care performance deficitIntervention: Assist with ADL's as needed Focus: The resident is at risk for oral/dental health problems r/t possible dental carriesIntervention: Provide mouth care as per ADL personal hygiene On 07/20/2026 at 11:10 a.m., an interview was conducted with Resident #1. She stated she had not been provided oral care on this date. She stated she had personal history of severe dry mouth and would often have to ask to be swabbed with mouth wash to help alleviate dry mouth. She stated she was dependent on staff to brush her teeth. Resident #1 stated if she didn't request for assistance for oral care to be performed it would not be provided. She stated she preferred to have oral care performed twice daily. On 07/21/2026 at 11:47 a.m., an interview with observation was conducted with Resident #1. She denied being provided oral care on 07/20/2026 and 07/21/2026 by staff. An observation was made of yellow plaque like substance on teeth. She stated the lack of oral care made her feel gross. On 07/21/2026 at 1:55 p.m., an interview was conducted with S3CNA. She stated CNAs were responsible for offering and providing oral care to residents. She stated she did not offer Resident #1 oral care on 07/20/2026 and 07/21/2026. She stated oral care should be offered daily. S3CNA confirmed she should have offered oral care and did not. On 07/22/2026 at 3:40p.m., an interview was conducted with S1ADM and S2DON. S1ADM and S2DON stated oral care should be offered at minimal daily and on an as needed basis. S1ADM and S2DON stated Resident #1 was dependent on staff to carry out ADL's to maintain optimal oral health. S1ADM and S2DON confirmed oral care should have been provided.

Based on observations, record review and interviews, the facility failed to have sufficient LPN staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment and observations of untimely medication administration. The deficiency had the potential to affect the facility's total census of 155 residents. Findings:Review of the facility's assessment, dated 05/02/2025, revealed LPN staffing needs for day, evening and night shift required 1 LPN per 23.5 Residents. Review of Facility's Census dated 04/20/2026 revealed Hall A had 52 residents, Hall B had 53 residents, and Hall C had 49 residents. Review of the Posted Daily Staffing Shift Detail revealed 6 LPN's scheduled on the day, evening and night shift on 04/20/2026 and 04/21/2026. An observation was conducted of Hall A, B, and C on 04/20/2026 from 8:33 a.m. to 9:57 a.m. which revealed 2 LPN's providing resident care on Hall A, Hall B, and Hall C. On 04/20/2026 at 9:57 a.m., an observation was made of S3LPN on Hall C. S3LPN was administering Resident #151's 7:30 a.m. and 8:00 a.m. scheduled medications. S3LPN confirmed Resident #151's medication administration was late. S3LPN stated Hall C residents had a higher acuity and she was not able to administer 8:00 a.m. medications timely with the current staffing of 2 LPNs. On 04/20/2026 at 10:40 a.m., an observation was made of S5LPN on Hall C. S5LPN was administering Resident #67's 8:00 a.m. medications. S5LPN confirmed Resident #67's medication administration was late. S5LPN stated Hall C residents had a higher acuity and she was not able to administer 8:00 a.m. medications timely with the current staffing of 2 LPNs. On 04/21/2026 at 10:13 a.m., an interview was conducted with S2ADON. S2ADON stated Hall C had higher acuity residents and 2 LPN's scheduled to provide resident care was not sufficient. On 04/21/2026 at 3:00 p.m., an interview was conducted with S5LPN. S5LPN stated when she began working at the facility, Hall C had 3 LPN's scheduled to provide resident care. S5LPN stated for the last 2 weeks Hall C was assigned 2 LPN's providing resident care. S5LPN stated Hall C had long term care residents and skilled care residents. She stated she was assigned to provide care to 24 long term care residents and S3LPN was assigned to provide care to 25 skilled care residents on Hall C. S5LPN stated on 04/20/2026 she completed scheduled 8:00 a.m. medications after 11:00 a.m. and on 04/21/2026 she completed scheduled 8:00 a.m. medications after 9:30 a.m. She stated residents on Hall C required basic nursing skills and it was not manageable to complete the nursing task timely with only 2 scheduled LPN's providing care. She confirmed on 04/20/2026 and 04/21/2026 she administered and 8:00 a.m. scheduled medications late due to 2 LPN's staffed on Hall C. On 04/21/2026 at 3:00 p.m., an interview was conducted with S3LPN. S3LPN stated when she began working at the facility, Hall C had 3 LPN's scheduled to provide resident care. S3LPN stated for the last 2 weeks Hall C was assigned 2 LPN's providing resident care. S3LPN stated Hall C had long term care residents and skilled care residents. S3LPN stated she was assigned to provide care to 25 skilled care residents and S5LPN was assigned to 24 long term care residents on Hall C. She stated on 04/20/2026 she completed her scheduled 7:30 a.m. and 8:00 a.m. medications after 11:00 a.m. and on 04/21/2026 she completed scheduled 8:00 a.m. medications after 10:00 a.m. She stated residents on Hall C required basic nursing skills and it was not manageable to complete the nursing task timely with only 2 scheduled LPN's providing care. She confirmed on 04/20/2026 and 04/21/2026 she administered 7:30 and 8:00 a.m. scheduled medications late due to 2 LPN's staffed on Hall C. On 04/21/2026 at 11:46 a.m., an interview was conducted with S6NP. She stated residents residing on Hall C were very sick and required a high acuity of nursing care. S6NP stated Hall C needed 3 LPNs scheduled to provider resident care on all shifts. On 04/21/2026 at 1:36 p.m., an interview was conducted with S1ADM. S1ADM confirmed on 04/20/2026 and 04/21/2026 the facility had 6 LPN's scheduled on the day, evening and night shift with 2 LPN assigned to Hall A, Hall B and Hall C. She confirmed the facility assessment stated 1 LPN per 23.5 residents but the LPN's could manage nursing care for 2 additional residents, for a total of 25 residents.

Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 36% during the medication administration observation. A total of 36 opportunities were observed, which included 13 medication errors for Resident #151 out of 5 residents observed for medication administration. This failed practice had the potential to affect any of the 155 residents currently residing in the facility. Review of the facilities policy titled, Medication Administration with a revised date of 04/2022, revealed, in part:11. Compare medication with MAR to verify resident name, medication name, form, dose, route and time.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Review of Resident #151's current Physician Orders and MAR revealed the following medications were scheduled for administration at 7:30 a.m.Pantoprazole Sodium Tablet Delayed Release 40 MG, Give 1 tablet by mouth one time a day; and the following medications were scheduled at 8:00 a.m. Amlodipine Besylate 10 MG, Give 1 tablet by mouth one time a day;Arginaid two times a day;Ascorbic Acid 500 MG, Give 1 tablet by mouth one time a day;Aspirin 81 MG, Give 1 tablet by mouth one time a day;Atorvastatin Calcium 40 MG, Give 1 tablet by mouth one time a day;Clopidogrel Bisulfate 75 MG, Give 1 tablet by mouth one time a day;Escitalopram Oxalate 10 MG, Give 1 tablet by mouth one time a day;Isosorbide Mononitrate Extended Release 24 Hour 30 MG, Give 1 tablet by mouth one time a day;Multiple Vitamin Tablet Give 1 tablet by mouth one time a day;Zinc Sulfate 220 MG, Give 1 capsule by mouth one time a day andMetoprolol Succinate Extended Release 24 Hour 25 MG, Give 1 tablet by mouth one time a day. On 04/20/2026 at 9:57 a.m., an observation was made of S3LPN administering Resident #151's scheduled 7:30 a.m. and 8:00 a.m. medications. S3LPN confirmed she did not administer the scheduled 7:30 a.m. and 8:00 a.m. medications within the standard timeframe of one hour before or one hour after the scheduled time and Metoprolol was not available for administration. On 04/21/2026 at 1:36 p.m., an interview was conducted with S1ADM. S1ADM stated scheduled 7:30 a.m. and 8:00 a.m. medications administered at 9:57 a.m. was considered late. She confirmed it was a professional standard that nurses administer medications one hour prior to or one hour after the scheduled time and all medications should be available for administration at the scheduled time.

Based on observation, interviews, and record review, the facility failed to ensure medications were properly stored in 1 (MedCart 1) of 4 medication carts observed for medication storage.Review of the facility's policy titled Medication Storage dated 01/2026 revealed in part, the following:1.a. All drugs will be stored in locked compartments (medication carts).An observation was made on 04/21/2026 at 2:32 p.m. of MedCart 1 unlocked, unsupervised, and located outside the nurses' station. Multiple residents were observed walking near the unlocked, unsupervised medication cart. An interview was conducted on 04/21/2026 at 2:40 p.m. with S2ADON. She confirmed MedCart 1 was unlocked and supervised. She opened the top drawer of MedCart 1 and observed 3 medication cups, each with loose pills located inside. She confirmed loose pills should not have been located in the medication cart and confirmed all medication carts should have been locked when unattended by a nurse.An interview was conducted on 04/22/2026 at 2:45 p.m. with S12ADM. She confirmed loose pills should not have been located in the medication cart and confirmed all medication carts should have been locked when unattended by a nurse.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to perform proper hand hygiene and gloving practices for 2 (#1 and #106) of 8 residents observed during direct care.Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to perform proper hand hygiene and gloving practices for 2 (#1 and #106) of 8 residents observed during direct care. Findings: Review of the facility's policy titled Hand Hygiene, with an effective date of 10/2025, revealed the following, in part:Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, patients, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines:2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table:Use either soap and water or alcohol based hand rub when:Before and after handling clean or soiled dressingsAfter handling items potentially contaminated with blood, body fluids, secretions, or excretionsWhen, during resident care, moving from a contaminated body site to a clean body siteAfter assistance with personal body functions 6. Additional considerations:a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Resident #1Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Tracheostomy and Non-Traumatic Intracranial Hemorrhage. On 04/21/2026 at 8:39 a.m., an observation was made of S11RT performing oral care and tracheostomy care for Resident #1. S11RT provided oral care to Resident #1. Then without removing soiled gloves and performing hand hygiene, S11RT removed Resident #1's tracheostomy dressing, cleaned the tracheostomy site, and removed the inner cannula of the tracheostomy. Then without removing soiled gloves and performing hand hygiene, S11RT put a new inner cannula in the tracheostomy and then applied a clean dressing to the tracheostomy site.Then S11RT removed her gloves and washed her hands. On 04/21/2026 at 8:45 a.m., an interview was conducted with S11RT. She confirmed the above observation. S11RT stated she was unaware she was supposed to remove her gloves and perform hand hygiene between oral care and tracheostomy care. She stated she was unaware she was supposed to remove her gloves and perform hand hygiene when moving from a contaminated body site to a clean body site. Resident #106Review of Resident #106's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Stage 4 Pressure Ulcer of Sacral Region. On 04/20/2026 at 1:21 p.m., an observation was made of S13WC and S14WC performing wound care to Resident #106's sacral pressure ulcer. S13WC and S14WC donned clean gloves and gowns. S14WC cleaned Resident #106's pressure ulcer. S14WC removed her soiled gloves, and without performing hand hygiene, applied clean gloves. S14WC applied the dressing to the wound. S14WC removed her soiled gown and gloves, and without performing hand hygiene, exited the room. S14WC proceeded to look through 3 drawers on the wound care cart at the door for tape. S14WC handed the tape to S13WC and S13WC secure the dressing. S13WC removed his gown and gloves and performed hand hygiene prior to exiting the room. On 04/20/2026 at 1:32 p.m., an interview was conducted with S14WC. She confirmed the above observation. She confirmed she should have performed hand hygiene between glove changes and prior to exiting Resident #106's room. On 04/21/2026 at 3:19 p.m., an interview was conducted with S9IP. She was made aware of Resident #106's incontinence and wound care observations. She confirmed hand hygiene should be performed between glove changes and prior to exiting a resident's room. On 04/22/2026 at 10:20 a.m., an interview was conducted with S1DON. She was made aware of Resident #1's oral care and tracheostomy care observation. She confirmed gloves should have been changed and hand hygiene performed between Resident #1's oral care and tracheostomy care. She further confirmed any time a staff member moved from a contaminated body site to a clean body site, gloves should be changed and hand hygiene performed. S1DON was made aware of Resident #106's incontinence and wound care observations. She confirmed hand hygiene should have been performed between glove changes and prior to exiting the resident's room.

Based on observations, interviews, and record review, the facility failed to ensure resident's room was clean and maintained in a sanitary manner for 1 (#101) of 2 sampled residents reviewed for environment. The facility failed to ensure Resident #101's room and restroom were properly cleaned and free of odor.Review of the facility's policy titled Routine Cleaning and Disinfection, with an effective date of 10/2025, revealed the following, in part:Policy:It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Policy Explanation and Compliance Guidelines:3. Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas12. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. Review of Resident #101's clinical record revealed she was admitted to the facility on [DATE] with a diagnosis of Glaucoma. Review of Resident #101's Quarterly MDS with an ARD of 01/07/2026 revealed a BIMS of 13, which indicated she was cognitively intact. On 04/20/2026 at 9:03 a.m., an observation was made of Resident #101's room and restroom. Upon entering Resident #101's room, a foul smell was noted. A large cobweb was observed in her room above the air conditioning unit, at the bottom of Resident #101's window. An observation of Resident #101's restroom revealed a black substance on the restroom floor with a stronger foul odor noted upon opening the restroom door. An observation of the shower revealed a cobweb between two shampoo bottles on the shower wall. On 04/21/2026 at 12:24 p.m., an interview was conducted with Resident #101. She stated she used her restroom and was able use her toilet independently. She stated she could not see her floors due to her eyesight and would not know if they were cleaned or not. She stated she did not refuse for housekeeping to clean her room. At that time, an observation was made of Resident #101's room and restroom. There was a cobweb observed on top of her air conditioning unit, at the base of her window. An observation of her restroom revealed there was a black substance over her restroom floor and the base of the toilet. The toilet paper holder on the wall next to the toilet was broken. Part of the toilet paper holder was stuck under the baseboard behind the toilet, as the baseboard was observed coming off of the wall. A strong foul odor was present in the restroom. On 04/21/2026 at 2:32 p.m., an observation was made of Resident #101's restroom with S7CNA. S7CNA confirmed there was a foul odor in the restroom. She confirmed the restroom was dirty and needed to be cleaned. S7CNA stated Resident #101 was independent for toileting so she was unsure how long the restroom had been like that. On 04/21/2026 at 1:42 p.m., an interview was conducted with S8HSK. S8HSK stated she was responsible for cleaning Resident #101's room and restroom. S8HSK stated Resident #101 had never refused for her room to be cleaned. At that time, an observation was made of Resident #101's room and restroom with S8HSK. S8HSK confirmed there was a cobweb above Resident #101's air conditioning unit and in the shower between the shampoo bottles and should not have been. She stated Resident #101's restroom smelled like sewage. She confirmed the toilet paper holder on the wall was broken and part of the toilet paper holder was stuck under the baseboard behind the toilet, as the baseboard was coming off of the wall. She confirmed there was a black substance all over Resident #101's bathroom floor. She stated she cleaned the restroom floor, but it did not help the state of the restroom. She stated she reported the restroom odor and restroom status to S9IP in February 2026. She confirmed Resident #101's room and restroom should be have been clean and sanitary. Review of the facility's Maintenance Log dated February 2026-current revealed no entries for Resident #101's room/restroom. On 04/21/2026 at 2:45 p.m., an interview was conducted with S9IP. S9IP stated the state of Resident #101's restroom was brought to her attention last week. She stated reported it S10MD. She stated S10MD stated he was going to check it out. On 04/21/2026 at 2:51 p.m., an interview was conducted with S10MD. He stated he was notified about the state of Resident #101's restroom approximately a month ago. He stated he did not document it in his maintenance log. He stated Resident #101 had ongoing issues with her restroom. He stated we are going to take care of it. He confirmed as of 04/21/2026, nothing had been initiated to fix Resident #101's restroom issues. On 04/21/2026 at 2:57 p.m., an observation was made of Resident #101's restroom with S10MD. He confirmed there was a foul odor in Resident #101's restroom and confirmed the toilet paper holder was off of the wall. S10MD observed the baseboards and confirmed part of the toilet paper holder was stuck into the baseboard behind the resident's toilet. He confirmed there was a black substance on the restroom floors. He stated the restroom needed a good cleaning and needed cleaned with bleach before he could tell what needed fixed. On 04/22/2026 at 10:15 a.m., an interview was conducted with S12ADM. She stated she was notified of Resident #101's restroom status on 04/21/2026. S12ADM was made aware of all observations above. S12ADM confirmed Resident #101's room and restroom should have been clean and sanitary.

Based on observation, record review, and interviews, the facility failed to ensure prescribed medications were available for administration for 1 (#151) of 5 residents reviewed for medication availability. This failed practice had the potential to affect any of the 152 residents currently residing in the facility.Review of facility's policy titled Medication Reordering revealed the following, in part:2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner.3. When administering medications, nurses must monitor remaining supply and reorder medications timely to prevent omissions, time permitting. Review of Resident #151's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnosis including Essential Hypertension. Review of Resident #151's April 2026 Physician Orders revealed an order for Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG, Give 1 tablet by mouth one time a day.Review of Resident #151's April 2026 MAR revealed an order Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG, scheduled for 8:00 a.m. administration. An observation and interview was conducted on 04/20/2026 at 9:57 a.m. with S3LPN during medication administration. Observation revealed S3LPN did not have Metoprolol on the medication cart or in the medication storage room to be administered to Resident #151. S3LPN confirmed she did not have the Metoprolol to administer to Resident #151. S3LPN confirmed the medication was not reordered from the pharmacy as of 04/20/2026, and should have been reordered by any nurse administering medications 7 days in advance prior to running out to ensure the facility had the medication available for administration. An interview was conducted with S4PHAR on 04/21/2026 at 12:43 p.m. S4PHAR stated the process to reorder medications was for staff to log into PCC and complete a reorder request. S4PHAR confirmed he had not received a reorder request for Resident #151's Metoprolol prior to 04/20/2026. An interview was conducted with S2ADON on 04/21/2026 at 10:13 a.m. S2ADON stated the process for ordering medications was to send an order when they had 7 medication pills remaining. S2ADON confirmed Resident #151's Metoprolol should have been available to administer on 04/20/2026 during the scheduled 8:00 a.m. medication administration time. An interview was conducted on 04/21/2026 at 1:36 p.m. with S1ADM. S1ADM confirmed medications ordered by the physician should be available for administration for the residents at all times. S1ADM further confirmed she expected nurses to request medication refills from the pharmacy prior to running out.

Based on record review, observations, and interviews, the facility failed to provide appropriate treatment and services for 1 (#1) resident of 4 residents reviewed for tube feedings. The facility failed to ensure:1. Resident #1's tube feeding bag was changed every 24 hours; and 2. Resident #1's tube feeding formula and free water flushes were administered per physician's orders.Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Cerebral Infarction, Dysphagia following Cerebral Infarction, and Gastrostomy status. Review of Resident #1's Current Physician Orders revealed an order dated 10/23/2025 for enteral feed every shift: Continuous feed: Jevity 1.5 at 70 ml per hour and 170 ml water flush every four hours. On 03/30/2026 at 11:35 a.m., an observation was made of Resident #1's tube feeding infusing at 50 ml per hour, with the pump set at 165 ml flush every 5 hours. The tube feeding was labeled and dated as started on 03/29/2026 at 5:40 a.m. On 03/30/2026 at 2:37 p.m., another observation was made of Resident #1's tube feeding infusing at 50 ml per hour, with the pump set at 165 ml flush every 5 hours. The tube feeding was labeled and dated as started on 03/29/2026 at 5:40 a.m.On 03/30/2026 at 2:40 p.m., an observation and interview was conducted with S2LPN. She observed the aforementioned findings and confirmed Resident #1's tube feeding was infusing at 50 ml per hour, with the pump set to infuse at 165 ml flush every 5 hours. S2LPN confirmed Resident #1's tube feeding was ordered to infuse at 70 ml per hour with 170 ml water flush every four hours and was not infusing at the correct ordered rate. She stated tube feeding and water flushes should be administered at the ordered rate. S2LPN further confirmed the tube feeding was labeled and dated as started on 03/29/2026 at 5:40 a.m. S2LPN confirmed the tube feeding bag should have been changed after 24 hours of use and was not. On 03/30/2026 at 3:35 p.m., an interview was conducted with S1ADON. She was notified of the aforementioned findings. She stated tube feedings and water bags are to be changed every 24 hours. She confirmed it was not acceptable for a tube feeding labeled and dated 03/29/2026 at 5:40 a.m. to still be infusing on 03/30/2026 past 5:40 a.m. She confirmed nurses are expected to administer tube feedings and water flushes at the ordered rate per physician orders.

Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 60% during the medication administration observation. A total of 65 opportunities were observed, which included 39 medication errors with Resident #3, #R1, #R2, #R3, and #R4 of 5 residents observed for medication administration. This failed practice had the potential to affect any of the 152 residents currently residing in the facility. Review of the facilities policy titled, Medication Administration with a revised date of 04/2022, revealed, in part: 11. Compare medication with MAR to verify resident name, medication name, form, dose, route and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Resident #3 Review of Resident #3's current Physician Orders revealed: Hydralazine HCL 10 mg one tablet by mouth two times a days at 8:00 am and 5:00 p.m. On 02/18/2026 at 9:36 a.m., an observation was made of S2LPN. S2LPN was observed not administering Resident #3's Hydralazine HCL 10 mg tablet. On 02/18/2026 at 9:36 a.m. an interview was conducted with S2LPN. She confirmed the facility did not have the Hydralazine HCL in the facility to be administered to Resident #3. She confirmed the medication was not ordered from pharmacy as of 02/18/2026 at 9:36 a.m. Resident # R1 Review of Resident #R1's current Physician Orders revealed: Arginaid 1 packet by mouth twice daily at 8:00 a.m. and 4:00 p.m.Acetaminophen ER 650mg give 2 tablets by mouth two times a day for pain at 8:00 a.m. and 8:00 p.m. Vitamin C 500 mg 1 tablet by mouth two times daily at 8:00 a.m. and 4:00 p.m. Multivitamin with mineral 1 tablet by mouth daily at 8:00 a.m. Ferrous Gluconate 324 mg one tablet by mouth daily at 8:00 a.m. Vitamin B12-500 mcg 1 tablet by mouth daily at 8:00a.m. Ipratropium- Albuterol Solution 0.5-2.5 mg/3ML 1 vial inhaled twice daily at 8:00 a.m. and 5:00 p.m.Spironolactone 25 mg 1 tablet by mouth daily at 8:00 a.m. Metoprolol Succinate ER 25 mg 1 tablet by mouth daily at 8:00 a.m.Jardiance 10 mg 1 tablet by mouth daily at 8:00 a.m. Furosemide 40 mg 1 tablet by mouth daily at 8:00 a.m. An observation was conducted on 02/18/2026 at 10:47 a.m. of S3LPN administering the above medications to Resident #R1. An interview was conducted on 02/18/2026 at 10:36 a.m. with S3LPN. S3LPN confirmed that medications should be given between 8:00 a.m. and 10:00 a.m. She confirmed Resident #R1's medications were given late the morning of 02/18/2026. Resident #R2 Review of Resident #R2's current Physician Orders revealed: Amlodipine 10 mg 1 tablet by mouth daily at 8:00 a.m. Aspirin 81 mg 1 tablet by mouth daily at 8:00 a.m. Bupropion 150 mg 1 tablet by mouth daily at 8:00 a.m. Vitamin D 125 mcg give 1 tablet by mouth once daily at 8:00 a.m. Plavix 75 mg tablet give one tablet by mouth once daily at 8:00 a.m. Doxazosin 2mg tablet give 1 tablet by mouth daily at 8:00 a.m. Lexapro 20 mg 1 tablet by mouth daily at 8:00 a.m. Ezetimibe 10 mg tablet 1 tablet by mouth daily at 8:00 a.m. Isosorbide Mononitrate ER 30 mg 1 tablet by mouth daily at 8:00 a.m.Lamictal 25 mg tablet 1 tablet by mouth daily at 8:00 a.m. Multivitamin 1 tablet by mouth daily at 8:00 a.m. Flomax 0.4mg 1 capsule by mouth daily at 8:00 a.m. An observation was conducted on 02/18/2026 at 10:20 a.m. of S2LPN administering the above medications to Resident #R2. Resident #R3 Review of Resident #R3's current Physician Orders revealed: Allopurinol 300 mg tablet 1 by mouth twice daily at 8:00 a.m. and 5:00 p.m. Baclofen 20 mg 1 tablet by mouth 3 times daily at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Culturelle Oral Capsule 1 capsule by mouth once time daily at 8:00 a.m. Cymbalta 30 mg one capsule by mouth two times daily at 8:00 a.m. and 8:00 p.m. Gabapentin 600 mg 1 tablet by mouth three times daily at 8:00 a.m., 2:00 p.m., and 8:00 p.m.Multivitamin- Minerals 1 tablet by mouth daily at 8:00 a.m. Cilostazol 50 mg 1 tablet by mouth twice daily at 8:00 a.m. and 8:00 p.m. An observation was conducted on 02/18/2026 at 10:30 a.m. of S2LPN administering the above medications to Resident #R3. Resident #R4 Review of Resident #R4's current Physician Orders revealed: Aspirin 81 mg tablet 1 tablet by mouth daily at 8:00 a.m. Vitamin C 500 mg 1 tablet by mouth daily at 8:00 a.m. Jardiance 25 mg 1 tablet by mouth daily at 8:00 a.m. Losartan 50 mg 1 tablet by mouth daily at 8:00 a.m. Meloxicam 7.5 mg 1 tablet by mouth twice daily at 8:00 a.m. and 5:00 p.m. Protonix 40 mg 1 tablet by mouth daily at 8:00 a.m. Seroquel 100 mg 1 tablet by mouth twice daily at 8:00 a.m. and 8:00 p.m. Multivitamin 1 tablet by mouth daily at 8:00 a.m. An observation was conducted on 02/18/2026 at 10:37 a.m. of S2LPN administering the above medications to Resident #R4. On 02/18/2026 at 11:00 a.m. an interview was conducted with S2LPN. She confirmed the above observations of medication administration for Resident's #R2, #R3, and #R4. She confirmed morning medication pass started at 8:00 am and nurses have to administer medications from 7:00 a.m. - 9:00 a.m. She further confirmed that any medication administered after 10:00 a.m. was considered late. On 02/18/2026 at 12:00 p.m. an interview was conducted with S1ADM. She confirmed that nurses have one hour prior to scheduled medications and one hour after scheduled medications to administer meds. She confirmed that if a medication was given at 10:00 a.m. it was considered late. All medications should be administered within the appropriate time frame.

Based on observation, record review, and interviews, the facility failed to ensure prescribed medications were available for administration for 1 (#3) of 3 residents reviewed for medication availability. This failed practice had the potential to affect any of the 152 residents currently residing in the facility.Review of facility's policy titled Medication Reordering revealed the following, in part: 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. When administering medications, nurses must monitor remaining supply and reorder medications timely to prevent omissions, time permitting. Review of Resident #3's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnosis including Essential Hypertension. Review of Resident #3's current February 2026 Physician Orders revealed an order for Hydralazine HCL 10 mg one tablet by mouth two times a days with a start date of 01/06/2025. An observation ad interview was conducted on 02/18/2026 at 9:36 a.m. with S2LPN during medication administration. Observation revealed S2LPN did not have Hydralazine on the medication cart or in the medication storage room to be administered to Resident #3. S2LPN confirmed she did not have the Hydralazine in the facility to administer to Resident #3. She confirmed the MAR revealed Resident #3 received her last dose of Hydralazine 10 mg on 02/17/2026 at 17:00 p.m. She confirmed the medication was not reordered from the pharmacy as of 02/18/2026, and could have been reordered by any nurse administering medications 7 days in advance prior to running out to ensure the facility had the medication available for administration. Review of Resident #3's February 2026 MAR revealed no documented evidence Hydralazine 10 mg PO was administered on 02/18/2026 at the 8:00 a.m. dose. An interview was conducted on 02/19/2026 at 10:34 a.m. with S1ADM. S1ADM confirmed medications ordered by the physician should be available for administration for the residents at all times. S1ADM further confirmed she expected nurses to request medication refills from the pharmacy prior to running out.

Based on observations, interviews, and record review, the facility failed to ensure services provided met professional standards of quality for 1 (#1) of 3 residents reviewed with feeding tubes. The facility failed to ensure nursing staff:Clarified Resident #1's tube feeding orders with the physician; andVerified accurate administration of Resident #1's tube feeding rate prior to documenting administration of tube feedings. Findings: Review of the facility's policy titled, Care and Management of Feeding Tubes, revised 01/2025, revealed the following, in part:Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.Definitions:Feeding tube refers to a medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake.Policy Explanation and Compliance Guidelines:1. Feeding tubes will be utilized according to physician/nurse practitioner's orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration.9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided:e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders. Review of Resident #1's Clinical Record revealed an admission date of 01/20/2025 and diagnoses, which included Cerebral Infarction, Hemiplegia and Hemiparesis, Unspecified Protein-Calorie Malnutrition, Adult Failure to Thrive, Gastrostomy Status, Dysphagia, and Type 2 Diabetes Mellitus. Review of Resident #1's current Care Plan revealed the following, in part:Problem: The resident requires tube feeding related to Dysphagia; nothing by mouth.Interventions: The resident is dependent on tube feeding. See Medical Doctor orders for current feeding orders. 1.Review of Resident #1's current Physician Orders dated November 2025 revealed the following, in part:Start: 11/12/2025 - Twenty-two hours continuous tube feeding of Glucerna 1.5 at 50 mL/hr.Further review of the Physician's Orders revealed no order or documentation indicating when to hold the tube feeding for two hours in a twenty-four hour period. Review of Resident #1's Nurses' Notes dated 11/12/2025 through 11/24/2025 revealed no documentation of holding Resident #1's tube feedings for two hours daily. Further review revealed no documentation indicating when to hold the tube feeding daily. Review of Resident #1's MAR dated November 2025 revealed no documentation Resident #1's tube feeding was held for two hours daily. An interview was conducted with S4LPN on 11/24/2025 at 12:18 p.m. She reviewed Resident #1's clinical record. She confirmed Resident #1's tube feeding order for Glucerna 1.5 at 50 mL/hr for 22 hours per day. She confirmed there was not an order indicating when to hold the tube feeding for two hours in a twenty-four hour period, and there should have been. She stated she was unsure when the tube feeding was being held. She further confirmed Resident #1's current tube feeding order needed clarification. An interview was conducted with S1DON on 11/25/2025 at 9:55 a.m. She reviewed Resident #1's clinical record. She confirmed Resident #1's tube feeding order for Glucerna 1.5 at 50 mL/hr for 22 hours per day started on 11/12/2025. She confirmed there was no order or documentation in Resident #1's clinical record indicating when to hold the tube feeding for two hours in a twenty-four hour period. She stated the nurses should have obtained a clarification order from Resident #1's physician to reflect the times the tube feeding should have been held. 2.Review of Resident #1's Physician Orders dated November 2025 revealed the following, in part:Start: 09/28/2025; D/C date: 11/12/2025 - Twenty-two hours continuous tube feeding of Glucerna 1.5 at 40 mL/hr.Start: 11/12/2025, current order - Twenty-two hours continuous tube feeding of Glucerna 1.5 at 50 mL/hr. Review of Resident #1's MAR dated November 2025 revealed twenty-two hours continuous tube feeding of Glucerna 1.5 at 50 mL/hr to be signed as administered daily at 9:00 a.m. and 6:00 p.m. Further review revealed S4LPN documented administration of Resident #1's enteral feeding at 50 mL/hr on the following dates: 11/12/2025 at 6:00 p.m., 11/13/2025, 11/18/2025, 11/19/2025, 11/20/2025, 11/23/2025, and 11/24/2025 at 9:00 a.m. An observation was made of Resident #1 on 11/24/2025 at 8:59 a.m. She was lying in bed with tube feeding of Glucerna 1.5 infusing via pump at 40 mL/hr. An observation was made of S4LPN reconnecting Resident #1's tube feeding on 11/24/2025 at 12:12 p.m. She administered the Glucerna 1.5 at 40 mL/hr via pump. An interview was conducted with S4LPN on 11/24/2025 at 12:18 p.m. She confirmed Resident #1 was receiving Glucerna 1.5 at 40 mL/hr continuously. She reviewed Resident #1's tube feeding order and confirmed the tube feeding should have been infusing at 50 mL/hr for 22 hours per day. She confirmed she signed out the ordered tube feeding as being administered at 50 mL/hr when it was only infusing at 40 mL/hr. She confirmed she should have checked the tube feeding rate this morning prior to signing out the current physician ordered rate, and she did not. She stated she was unaware Resident #1's tube feeding rate had increased to 50 mL/hr. She stated Resident #1 had been receiving 40 mL/hr on her shifts. An interview was conducted with S1DON on 11/25/2025 at 9:55 a.m. She reviewed Resident #1's clinical record. She confirmed Resident #1's tube feeding order for Glucerna 1.5 at 50 mL/hr for 22 hours per day started on 11/12/2025. She confirmed the nurse should have verified Resident #1 was receiving tube feedings at the physician ordered rate. She confirmed the nurse should have verified Resident #1's tube feeding was infusing at the physician ordered rate prior to documenting administration of the tube feeding.

Based on observations, interviews, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to ensure the resident received tube feedings based on the comprehensive assessment for 1 (#1) of 3 residents reviewed with feeding tubes.Findings: Review of the facility's policy titled, Nutritional Management, and revised 05/2023, revealed the following, in part:Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.Compliance Guidelines:1. A systematic approach is used to optimize each resident's nutritional status:c. Developing and consistently implementing pertinent approaches.4. Care Plan implementation:d. Tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. Review of Resident #1's Clinical Record revealed an admission date of 01/20/2025 and diagnoses, which included Cerebral Infarction, Hemiplegia and Hemiparesis, Unspecified Protein-Calorie Malnutrition, Adult Failure to Thrive, Gastrostomy Status, Dysphagia, and Type 2 Diabetes Mellitus. Review of Resident #1's Physician Orders dated November 2025 revealed the following, in part:Start: 09/28/2025; D/C date: 11/12/2025 - Twenty-two hours continuous tube feeding of Glucerna 1.5 at 40 mL/hr.Start: 11/12/2025, current order - Twenty-two hours continuous tube feeding of Glucerna 1.5 at 50 mL/hr. Review of Resident #1's current Care Plan revealed the following, in part:Problem: The resident requires tube feeding related to Dysphagia; nothing by mouth.Interventions: The resident is dependent on tube feeding. See Medical Doctor orders for current feeding orders. Review of Resident #1's weight history from 08/29/2025 through 11/17/2025 revealed the following:08/29/2025 - 139.4 pounds;09/15/2025 - 136 pounds;10/10/2025 - 130 pounds; and11/17/2025 - 128.8 pounds. Review of Resident #1's Registered Dietician Note by S3RD dated 11/06/2025 revealed the following, in part:Current weight: 130 poundsTube feeding is not meeting Resident #1's daily nutrient needs. Current tube feeding: Glucerna 1.5 at 40 mL/hr for 22 hours per day.Tube feeding is providing 1320 kcal, meeting 81% of calories.Total daily needs: 1636-1800 kcalRecommendation: increase tube feeding rate to 50 mL/hr continuous. An observation was made of Resident #1 on 11/24/2025 at 8:59 a.m. She was lying in bed with tube feeding of Glucerna 1.5 infusing via pump at 40 mL/hr. An observation was made of S4LPN reconnecting Resident #1's tube feeding on 11/24/2025 at 12:12 p.m. She administered the Glucerna 1.5 at 40 mL/hr via pump. An interview was conducted with S4LPN on 11/24/2025 at 12:18 p.m. She confirmed Resident #1 was receiving Glucerna 1.5 at 40 mL/hr continuous. She reviewed Resident #1's tube feeding order and confirmed the tube feeding should have been infusing at 50 mL/hr for 22 hours per day. An interview was conducted with S3RD on 11/25/2025 at 8:59 a.m. She stated Resident #1 was receiving tube feeding only for nutrition. She confirmed, on 11/06/2025, she recommended to increase Resident #1's tube feeding rate to 50 mL/hr. She stated Resident #1's physician approved to increase her tube feeding rate, and therefore, the facility should have been administering the tube feeding at 50 mL/hr when the physician ordered it. She confirmed Resident #1 needed the Glucerna 1.5 at 50 mL/hr to increase her caloric intake to better meet her needs. An interview was conducted with S1DON on 11/25/2025 at 9:55 a.m. She reviewed Resident #1's RD note dated 11/06/2025 and confirmed the recommendation was to increase her Glucerna 1.5 to 50 mL/hr. She confirmed the physician's order was implemented on 11/12/2025 for Glucerna 1.5 at 50 mL/hr for 22 hours per day. She confirmed Resident #1's tube feeding should have been administered at the physician ordered rate. An interview was conducted with S2NP on 11/25/2025 at 10:45 a.m. She confirmed she was in agreement with increasing Resident #1's tube feeding rate to 50 mL/hr. She stated she expected Resident #1's tube feeding to be administered at the ordered rate of 50 mL/hr.

Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post discharge care and the reduction of factors leading to preventable readmissions for 1 (#1) of 2 (#1 and #3) residents reviewed for discharge. The facility failed to ensure: 1. The discharge needs of the resident were identified and resulted in the development of a discharge plan;2. Involve the interdisciplinary team in the ongoing process of developing the discharge plan;3. Document the resident had been asked about their interest in receiving information regarding returning to the community; and 4. Create a discharge summary that included a post-discharge plan indicating where the resident planned to reside, any arrangements that had been made for the resident's follow-up care and any post-discharge medical and non-medical services.Review of the facility's policy titled, Transfer and Discharge (Including AMA) and dated 04/2025 revealed the following, in part:Policy Explanation and Compliance Guidelines:12. Anticipated Discharges to the Communitya. Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care. b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results.ii. A final summary of the resident's statusiv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative which will assist the resident to adjust to his or her new living environment.e. The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge.f. Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative.Review of Resident #1's clinical record revealed he was initially admitted to the facility on [DATE] and discharged from the facility on 07/22/2025. Further review of his clinical record revealed no documentation of Resident #1's discharge planning process and an adequate, discharge summary. Review of Resident #1's Discharge MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/22/2025 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicted he was cognitively intact. On 09/10/2025 at 4:34 p.m., an interview was conducted with Resident #1. He stated he did not voice interest to staff pertaining to living within the community independently. He stated the facility was his home. He stated he did voice interest in going to rehab, but thought he would return to the facility after his treatment program was completed. On 09/10/2025 at 11:00 a.m., an interview was conducted with S2FADM. She stated Resident #1 resided at the facility for several years. She stated he was very independent and expressed to staff an interest in discharging from the facility to live within the community independently. She stated due to his history of alcohol abuse, he was discharged from the facility to Avenues Recovery Center with the understanding that he would then transition to community living. She stated she expected Avenues Recovery Center to assist Resident #1 with securing a permanent placement after his 45-day treatment program was completed. On 09/10/2025 at 11:19 a.m., an interview was conducted with S4SW. She stated during Resident #1's stay at the facility, he voiced interest in going to rehab and living within the community independently. She stated on 07/22/2025, she and Resident #1 participated in a phone call conference with an admission coordinator from Avenues Recover Center regarding their detox and rehabilitation program. She stated Resident #1 gave consent to admit to Avenues Recovery Center and was discharged from the facility effective on 07/22/2025. She stated she expected Avenues Recovery Center to assist Resident #1 with securing a permanent placement after his 45-day treatment program was completed.On 09/11/2025 at 10:02 a.m., an interview was conducted with S5NP. She stated she began working at the facility after Resident #1's discharge. She stated, however, if a resident wished to voluntarily discharge from the facility, their intent to discharge would need to be documented, an assessment would need to be completed by either the Nurse Practitioner or Physician to determine their capability to care for self and determine post-discharge needs. She further stated the resident's medical record should also feature a discharge order and an adequate, discharge summary to indicate the end of care at the facility and transition to the next level of care. On 09/11/2025 at 10:27 a.m., an interview was conducted with S3DON. She confirmed no documentation could be provided to reflect Resident #1's intent to discharge from the facility and return to living within the community independently. She further confirmed no documentation could be provided to reflect Resident #1 was involved in an ongoing process to develop an effective, discharge plan. Lastly, she confirmed Resident #1's medical record did not contain a discharge order or an adequate, discharge summary that would indicate the end of care at the facility and transition to next level of care. On 09/11/2025 at 11:27 a.m., an interview was conducted with S1ADM. She confirmed the facility failed to develop and implement an effective discharge planning process with Resident #1 and should have.

Based on interviews and record reviews, the facility failed to provide the resident or RP (Responsible Party) with written notice, which specifies the duration of the bed-hold policy at the time of transfer to the hospital for 2 (#2 and #3) of 3 (#1, #2, and #3) sampled residents.Review of the facility's Bed Hold and Returns policy, revised on 04/2025, revealed, in part:Policy:It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave.Policy Explanation and Compliance Guidelines:1. The facility will issue (2) written notice of bed hold policy to the resident/or resident representative as follows:1. As part of the admission packet and2. At the time of a transfer to the hospital or a therapeutic leave.The facility will provide the resident and/or the resident representative written information that specifies:a. the duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;b. The reserve bed payment policy in the state plan policy, if any.c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed.d. Conditions upon which the resident would return to the facility:i. The resident requires the services which the facility provides;ii. The resident is eligible for Medicare skilled services or Medicaid nursing facility services.4. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. Resident #2Review of Resident #2's Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Unsteadiness on Feet, Abnormalities of Gait and Mobility, Morbid Obesity, Unspecified Lack of Coordination, and Need for Assistance with Personal Care. Review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Review of Physician Orders dated 07/10/2025 through 09/09/2025 revealed the following:07/10/2025- Okay to transfer to Rehabilitation for evaluation and treatment. Review of Resident #2's record revealed no documented evidence, and the facility was unable to present any documentation showing Resident #2 or Resident #2's RP had received written notification of the bed hold policy when Resident #2 was transferred to the Rehabilitation hospital on [DATE]. Review of the facility's Emergency Transfer Log revealed Resident #2 was transferred to a local Rehabilitation hospital for therapy on 07/10/2025 with a return to facility date of 07/29/2025. On 09/10/2025 at 9:20 a.m., an interview was conducted with Resident #2. Resident #2 confirmed she was transferred to a local Rehabilitation hospital in July 2025, and stayed there for about 2 weeks for exercise, and to get stronger. Resident #2 confirmed she was not given any written information or notice, which specified the duration of the bed hold policy. She further confirmed she did not sign any forms related to a bed hold policy prior to her transfer on 07/10/2025. Resident #3Review of Resident #3's Clinical Record revealed Resident #3 as admitted to the facility on [DATE] with diagnoses, which included Displaced Bimalleolar Fracture of Right Lower Leg, and Other Abnormalities of Gait and Mobility. Review of Resident #3's admission Minimum Data Set (MDS), dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Review of Physician Orders dated 07/11/2025 through 08/08/2025 revealed the following:08/08/2025- Resident to be transferred to local hospital for surgery to right foot. Review of Resident #3's record revealed no documented evidence, and the facility was unable to present any documentation showing Resident #3 or Resident #3's RP had received written notification of the bed hold policy when Resident #3 was transferred to the local hospital on [DATE]. Review of the facility's Emergency Transfer Log revealed Resident #3 was transferred to a local hospital for surgery on 08/08/2025. On 09/11/2025 at 10:27 a.m., an interview was conducted with S3DON. S3DON confirmed Residents #2 and #3 were transferred from the facility on the aforementioned dates. S3DON confirmed there was no documented evidence the facility provided Residents #2, #3 or their RPs with a dated and signed written notice, which specified the duration of the bed-hold policy at the time of their transfers to the hospital, and there should have been. On 09/11/2025 at 11:27 a.m., an interview was conducted with S1ADM. S1ADM confirmed there was no documented evidence the facility provided Residents #2, #3 or their RPs with a dated and signed written notice, which specified the duration of the bed-hold policy at the time of their transfers to the hospital, and there should have been.

Based on observations and interviews, the facility failed to ensure dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service. The facility failed to ensure S18DW was competent to effectively and sanitarily perform the functions of the facility's dishwasher. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen. Findings: An observation was made of S18DW performing the dish washing process in the facility's kitchen on 05/05/2025 at 10:10 a.m. S18DW was observed to place 18 meal trays upright with two stacked together with no spacing between them in one washing tray. He was observed to stack 17 insulated food tray bases, one on top of the other, with no spacing between them and sent them through the dishwasher. A drink lid was observed between two insulated food tray bases after the washing process was complete and the food tray bases were holding water. An interview was conducted with S18DW at that time. He stated the dishwasher did not utilize a sanitizing solution and he did not know how to test the concentration. An observation was made of the dishes after being sent through the dishwasher on 05/05/2025 at 10:15 a.m. with S10DM. An interview was conducted with S10DM at that time. She confirmed the above observation. S10DM confirmed dishes should not have been stacked because they could not be effectively cleaned. She stated the dishes should have been placed in a tray basket, one per compartment/slot, for effective cleaning. S10DM stated the dishwasher utilized a sanitizing solution for sanitizing the dishes. An interview was conducted with S18DW on 05/05/2025 at 10:20 a.m. He stated he began working as a dishwasher at the facility 2 weeks ago. He stated he was oriented when he first started but was not trained on everything. He stated the dishwasher utilized only hot water for sanitation and did not utilize a sanitizing solution. He stated he was provided training on how to utilize the dishwasher, but was not trained on how to utilize the sanitation concentration test strips or when/how often he should test the sanitization solution concentration. An interview was conducted with S19DDM and S10DM on 05/06/2025 at 1:20 p.m. S10DM stated she was responsible to ensure S18DW was competent in using the dishwasher and effectively washing dishes. S19DDM stated S18DW should have been trained the dishwasher utilized a sanitizing solution for dish sanitization and he should have been trained how to test the concentration of the sanitizing solution. S19DDM stated S18DW should have been trained and competent to effectively load the dishes to ensure sanitization and how to test the sanitizing concentration. An interview was conducted with S1ADM on 05/07/2025 at 9:00 a.m. She stated S18DW should have been competent in utilizing the dishwasher. She stated S18DW should have been trained the dishwasher utilized hot water and sanitization and how to check the sanitation concentration of the dishwasher. She stated the dishwasher should have been trained on how to properly load the dishwasher to ensure the cleanliness and sanitation of the dishes. She confirmed, ultimately, the facility was responsible to ensure the functions of the kitchen and dietary services were carried out effectively.

Based on observations, interviews, and record reviews, the facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service when meals were served late on 05/05/2025 and 05/06/2025. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen. Findings: Review of the facility's policy dated 05/2023 and titled, Dietary Services - Staffing revealed the following, in part: Policy: The facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Policy Explanation and Compliance Guidelines for Staffing: 6. The facility will provide sufficient support personnel to safely and effectively carry out the supportive functions of the Food and Nutrition Services. These functions include, but are not limited to: a. Safe and timely meal preparation; c. Providing meals and/or supplements in accordance with residents' needs . preferences, and care plans Review of the facility's policy dated 05/2023 and titled, Frequency of Meals revealed the following, in part: Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals. Policy Explanation and Compliance Guidelines: 1. The facility has scheduled three regular meal times, comparable to normal meal times in the community. Review of the facility's Facility assessment dated [DATE] revealed the following, in part: Information about our staffing patterns: Food and Nutrition Services: Staffing in the dietary department is adequate as evidenced by timely meal service, consistent staffing assignments, adherence to dietary needs and preferences, and positive resident feedback on meals and service. Review of the posted meal times outside of the dining room revealed the following: Breakfast - 7:30 a.m. Lunch - 11:30 a.m. Dinner - 4:30 p.m. Review of the Dietary departments' time cards dated 05/05/2025 and 05/06/2025, revealed there were five dietary support personnel for breakfast and lunch. An observation was made of the first Hall A breakfast meal tray cart being prepared in the facility's kitchen on 05/05/2025 at 9:10 a.m. An observation was made of Hall B breakfast meal trays being passed out to residents on 05/05/2025 at 9:58 a.m. An interview was conducted with Resident #52 on 05/05/2025 at 10:05 a.m. She stated meal times were inconsistent and often came an hour or two late. An observation was made of Resident #9 eating her lunch on 05/05/2025 at 2:03 p.m. She stated she had just received her lunch tray. She stated meal trays were often passed out late and almost never on time as scheduled. She stated she wanted more consistent meal times. An interview was conducted with S13CNA on 05/05/2025 at 2:25 p.m. She stated lunch meal trays were scheduled to be passed out at 12:00 p.m. She stated Hall B meal trays were served at 1:30 p.m. today, which was late. An interview was conducted with S23CNA on 05/06/2025 at 12:57 p.m. She confirmed she was assigned to Hall A. She stated meal trays were supposed to be delivered at 8:00 a.m. for breakfast and 11:30 p.m. for lunch. She stated breakfast was usually delivered around 9:30 a.m. She stated sometimes the residents complained because the meal trays were late. She stated if the kitchen was short staffed, which was about two days per week, the trays were delivered late. An observation was made of the first Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 12:59 p.m. An observation was made of the second Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 1:18 p.m. An interview was conducted with Resident #22 on 05/07/2025 at 8:37 a.m. She stated meal trays were frequently delivered late. She stated lunch was frequently delivered around 2:00 p.m. An interview was conducted with S24LPN on 05/07/2025 at 8:45 a.m. She stated residents complained of late meal trays. An interview was conducted with Resident #94 on 05/07/2025 at 8:48 a.m. She stated the meal times were never consistent. She stated breakfast was delivered anywhere from 8:00 a.m. to 10:00 a.m., lunch from 12:30 p.m. to 2:00 p.m., and supper 6:00 p.m. to 8:00 p.m. She stated she wanted consistent meal times. She stated most meals were served after the posted meal times. An interview was conducted with S20DA on 05/07/2025 at 9:52 a.m. She stated the kitchen needed more staff to assist with carrying out the functions of the dietary service timely. She stated they each have to pitch in and help cook, serve, and clean. She stated they began serving lunch at 11:30 a.m., and the last tray went out at 1:30 p.m. She stated they would be able to get the trays out sooner if there were more dietary staff. An interview was conducted with S21DA on 05/07/2025 at 9:52 a.m. She stated the kitchen needed more staff to carry out the functions of the dietary service timely and effectively. She stated the meal trays would have been delivered sooner if there were more dietary staff. An interview was conducted with S22C on 05/07/2025 at 9:58 a.m. She stated the kitchen was very short staffed and needed more help. She stated she never got to take a break. She stated they had to cook, serve, clean, and set up. She stated with the current amount of staff, which was a total of five, meals were late daily. She stated the whole process of getting meal trays out did not get completed timely due to not having enough dietary staff. She confirmed the hall trays had been late due to not having enough staff. An interview was conducted with S10DM on 05/06/2025 at 1:11 p.m. She stated she had been short staffed in the kitchen. She stated she could not keep staff, they called out, or they didn't show up. She stated the dietary service was currently being carried out with one cook, one cook assistant, two dietary aides, and a dishwasher for each meal. She stated the kitchen needed one cook, one cook assistant, three dietary aides, and a dishwasher to effectively carry out the functions of the dietary service. She stated the scheduled meal times were 8:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for supper. She stated all residents should have been served within one hour of the scheduled meal time. She stated when the meal trays were late to the hallway, it was because she did not have enough staff in the kitchen. She confirmed she needed more dietary staff to carry out the functions of the dietary service effectively and timely. S10DM stated she was also acting as a dietary support personnel in addition to office duties and training new staff. An interview was conducted with S19DDM on 05/06/2025 at 1:20 p.m. She stated the facility was currently carrying out the functions of the dietary service with five staff for each meal. She stated the kitchen needed a total of at least six dietary staff for each meal to effectively carry out the functions of the dietary service. An interview was conducted with S1ADM on 05/07/2025 at 9:00 a.m. She stated scheduled meal times were breakfast at 8:00 a.m., lunch at 12:00 p.m., and supper at 5:00 p.m. She stated she would expect all meal trays to be delivered to the residents within 30-35 minutes of the posted meal time. She was made aware of the breakfast and lunch meal times observations on 05/05/2025 and 05/06/2025. She confirmed the observations of late meal times were unacceptable time frames for meal service. She stated there should have been enough dietary support personnel to effective carry out the functions of the dietary service. 52097

Based on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 2 (#19 and # 92) of 6 (#9, #19, #36, #53, #92 and #138) residents reviewed for PASRR. Findings: Resident #19 Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, Schizoaffective Disorder with an onset date of 10/01/2020. Review of Resident #19's most recent Level I PASRR Screening and Determination form revealed a previous assessment was performed on 07/05/2020. Review was attempted of Resident #19's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 10/01/2020, with no documentation available for review. An interview was conducted on 05/07/2025 at 2:15 p.m. with S9SW. S9SW confirmed Resident #19's Pre-admission Level I PASRR Screen and Determination was last submitted on 07/05/2020. She confirmed on 10/01/2020, Resident #19 received a new diagnosis of a relevant mental illness: Schizoaffective Disorder. She confirmed the facility did not resubmit a new Level I PASRR Screen and Determination with the onset of the new diagnosis. Resident #92 Review of Resident #92's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Fracture of Head of Right Radius, Chronic Pain, Insomnia, and Cognitive Communication Disorder. Resident #92 had diagnosis of Post Traumatic Stress Disorder dated 05/30/2024. Review of Resident #92's most recent Level I PASRR Screening and Determination form revealed her previous assessment was performed on 02/14/2024. Review was attempted of Resident #92's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 05/30/2024, with no documentation available for review. Review of Resident #92's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2025, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Further review revealed, in part, the following: Section I: Diagnoses I6100: Post Traumatic Stress Disorder - Checked. An interview was conducted on 05/07/2025 at 10:00 a.m. with S9SW. S9SW confirmed Resident #96's Pre-admission Level I PASRR Screen and Determination was most recently submitted on 02/14/2024. She confirmed on 05/30/2024, Resident #96 received a new diagnosis of a relevant mental illness: Post Traumatic Stress Disorder. She confirmed the facility did not resubmit a new Level I PASRR Screen and Determination with the onset of the new diagnosis, and should have. An interview was conducted on 05/07/2025 at 3:00 p.m. with S2DON. He confirmed if a resident received a new relevant mental illness diagnosis a resident review should be resubmitted. 47732

52699 Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#11 and #111) of 4 (#9, #11, #30, and #111) residents reviewed for ADL's. The facility failed to: 1. trim fingernails for Resident #111; and 2. provide incontinent care in a timely manner for Resident #11. Findings: Review of the facility's policy, Nail Care , with a revision date of 09/2017, revealed the following, in part: Policy: Nail care should be included in a Patient's daily hygiene; the best time is during the Patient's bath. Procedure: -Cut nails immediately after bathing when they are the softest and easiest to cut. -Cut nails straight across with a nail clipper. 1. Resident #111 Review of the clinical record for Resident #111 revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status and Traumatic Brain Injury. Review of the most recent MDS with ARD (Assessment Reference Date) of 04/13/2025 revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated severe cognitive impairment. Review of Resident #111's current Care Plan revealed the following: Problem: The resident has an ADL self-care performance deficit. Interventions: Assist with ADLs On 05/06/2025 at 8:30 a.m., an observation and interview was conducted with Resident #111. His fingernails were long and approximately 0.5 cm past the tips of all ten of his fingers. Resident #111 stated if he had clippers and if he was able, he would trim his own nails. He stated he would like for his fingernails to be trimmed. He stated he received a bath on 05/05/2025 and his nails were not trimmed at that time. On 05/06/2025 at 9:00 a.m., an observation and interview was conducted with S6LPN. She stated CNAs were responsible for cleaning and trimming the fingernails of residents who do not have diabetes. She further stated nail care is usually provided along with a resident's bath. S6LPN observed and confirmed Resident #111's were too long and needed to be trimmed. On 05/06/2025 at 9:36 a.m., an observation was made with S12CNAS of Resident #111's fingernails. Resident #111 informed S12CNAS he had received a bath on 05/05/2025 and had not been provided nail care. She stated CNAs were responsible for trimming the nails of residents that did not have diabetes. S12CNAS confirmed resident #111's nails were too long and needed to be trimmed. On 05/06/2025 at 9:44 a.m., an interview was conducted with S3ADON. She confirmed that resident's nails should be kept clean and trimmed. 2. Resident #11 Review of the clinical record for Resident #11 revealed he was admitted to the facility on [DATE] with diagnoses which included Morbid Obesity, Hemiplegia, and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of the most recent MDS with ARD (Assessment Reference Date) of 01/28/2025 revealed BIMS (Brief Interview for Mental Status) score of 15, which indicated no cognitive impairment. Review of Resident #11's current care plan revealed the following: Problem: The resident has bowel incontinence related to immobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use. Intervention: Check resident every two hours and assist with toileting as needed; provide pericare after each incontinent episode. On 05/06/2025 at 9:00 a.m., an interview was conducted with Resident #11. He stated he was currently soiled with urine and feces and had been for approximately 2.5 hours. He stated he initiated his call light again about an hour ago and no one has come to clean him yet. On 05/06/2025 at 9:32 a.m., an interview was conducted with S15CNA. She stated she was aware Resident #11 was soiled at this time. She stated I am not going to change him now. It takes two people and about an hour to get him cleaned up. On 05/06/2025 at 9:50 a.m., an interview was conducted with S2DON. He was made aware of Resident #11 being soiled for approximately 2.5 hours. He stated the policy regarding incontinence care was to clean them as soon as possible. He stated it was not acceptable for a resident to remain soiled for this period of time.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received therapeutic diets as ordered by the physician for 3 of 3 (#7, #39, and #40) residents reviewed with double/large portions with meals. Findings: Review of the facility's policy titled, Therapeutic Diet Orders with a revision date of 11/2024 revealed the following, in part: Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by the physician, and/or assessed by the interdisciplinary team to support the patient's/resident's treatment/plan of care, in accordance with his/her goals and preferences. Policy explanation and compliance guidelines: 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Resident #7 Review of Resident #7's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #7's current Physician Orders revealed a diet order for double portions. Review of Resident #7's lunch Meal Ticket dated 05/05/2025 revealed she should have received double portions. An observation was made of Resident #7's lunch meal on 05/05/2025 at 12:46 p.m. Her meal ticket revealed she should have been served double portions. Her lunch plate contained one taco, one serving of rice, and one serving of corn. An interview was conducted with Resident #7 at that time. She stated she only received single portions of the lunch meal and should have received double portions. Resident #39 Review of Resident #39's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #7's current Physician Orders revealed a diet order for large portions. Review of Resident #39's lunch Meal Ticket dated 05/05/2025 revealed he should have received large portions. An observation was made of Resident #39's lunch meal on 05/05/2025 at 12:48 p.m. His meal ticket revealed he should have been served large portions. His lunch plate contained one taco, one serving of rice, and one serving of corn. An interview was conducted with Resident #39 at that time. He stated he only received single portions of the lunch meal and should have received double portions. Resident #40 Review of Resident #40's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #40's current Physician Orders revealed a diet order for double portions. Review of Resident #40's lunch Meal Ticket dated 05/05/2025 revealed he should have received double portions. An observation was made of Resident #40's lunch meal on 05/05/2025 at 12:49 p.m. His meal ticket revealed he should have been served double portions. His lunch plate contained one taco, one serving of rice, and one serving of corn. An interview was conducted with Resident #40 at that time. He stated he only received single portions of the lunch meal and should have received double portions. An observation was made of Residents #7, #39, and #40 with S11CNA on 05/05/2025 at 12:50 p.m. S11CNA confirmed Residents #7, #39, and #40 received a single portion of the lunch meal. She confirmed Residents #7 and #40's meal tickets revealed they should have received double portions. S11CNA confirmed Resident #39's meal ticket revealed he should have received large portions. She stated large portions was double portions. An interview was conducted with S10DM on 05/05/2025 at 12:55 p.m. She reviewed Residents #7, #39, and #40 meal tickets and confirmed they should have received double portions. She stated large portions meant the same thing as double portions. An interview was conducted with S4ADON on 05/06/2025 at 8:42 a.m. She confirmed Residents #7, #39, and #40 should have received double portions as ordered by the physician and determined by the interdisciplinary team. She stated any resident with an order for double portions or double/large portions on their meal ticket should have received them.

Based on observations, interviews, and record reviews, the facility failed to ensure meals were provided at regular meal times comparable to normal mealtimes in the community and consistent with facility scheduled meal times for 2 (Hall A and Hall B) of 3 (Hall A, Hall B, and Hall C) halls observed for dining. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen. Findings: Review of the facility's policy dated 05/2023 and titled, Frequency of Meals revealed the following, in part: Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals. Policy Explanation and Compliance Guidelines: 1. The facility has scheduled three regular meal times, comparable to normal meal times in the community. Review of the posted meal times outside of the facility's dining room revealed the following: Breakfast - 7:30 a.m. Lunch - 11:30 a.m. Dinner - 4:30 p.m. An observation was made of the first Hall A breakfast meal tray cart being prepared in the facility's kitchen on 05/05/2025 at 9:10 a.m. An observation was made of Hall B breakfast meal trays being passed out to residents on 05/05/2025 at 9:58 a.m. An interview was conducted with Resident #52 on 05/05/2025 at 10:05 a.m. She stated meal times were inconsistent and often came an hour or two late. An observation was made of Resident #9 eating her lunch on 05/05/2025 at 2:03 p.m. She stated she had just received her lunch tray. She stated meal trays were often passed out late and were almost never on time as scheduled. She stated she wanted more consistent meal times. An interview was conducted with S13CNA on 05/05/2025 at 2:25 p.m. She stated lunch meal trays were scheduled to be delivered at 12:00 p.m. She stated Hall B meal trays were delivered at 1:30 p.m. today, which was late. An interview was conducted with S23CNA on 05/06/2025 at 12:57 p.m. She confirmed she was assigned to Hall A. She stated meal trays were supposed to be delivered at 8:00 a.m. for breakfast and 11:30 p.m. for lunch. She stated breakfast was usually delivered around 9:30 a.m. She stated sometimes the residents complained because the meal trays were late. An observation was made of the first Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 12:59 p.m. An observation was made of the second Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 1:18 p.m. An interview was conducted with Resident #22 on 05/07/2025 at 8:37 a.m. She stated meal trays were frequently delivered late. She stated lunch was frequently delivered around 2:00 p.m. An interview was conducted with S24LPN on 05/07/2025 at 8:45 a.m. She stated residents complained of late meal trays. An interview was conducted with Resident #94 on 05/07/2025 at 8:48 a.m. She stated the meal times were never consistent. She stated breakfast was delivered anywhere from 8:00 a.m. - 10:00 a.m., lunch from 12:30 p.m. - 2:00 p.m., and supper 6:00 p.m. - 8:00 p.m. She stated she wanted consistent meal times. She stated most all meals were delivered after the posted meal times. An interview was conducted with S10DM on 05/06/2025 at 1:11 p.m. She stated scheduled meal times were 8:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for supper. She stated all residents should have been served within one hour of the scheduled meal time. An interview was conducted with S1ADM on 05/07/2025 at 9:00 a.m. She stated scheduled meal times were breakfast at 8:00 a.m., lunch at 12:00 p.m., and supper at 5:00 p.m. She stated she would expect all meal trays should have been delivered to the residents within 30 to 35 minutes of the posted meal time. She was made aware of the breakfast and lunch meal time observations on 05/05/2025 and 05/06/2025. She confirmed the observations of late meal times were unacceptable time frames for meal service. 47191 52097

Based on observations, interviews, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure 1. Capillary blood glucose levels were administered in accordance with professional standards of practice and residents' person centered plans of care for 1 (#9) of 13 (1#, #2, #3, #6, #8, #9, #12, R1, R4, R5, R6, R7, R8) residents reviewed; and 2. The facility had a system in place to ensure medications that included heart failure medication, hyperglycemic control medications, and narcotic analgesics were appropriately administered for 6 (#1, #6, #9 #12, R5, R7) of 20 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, R1, R2, R3, R4, R5, R6, R7, and R8) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 beginning on 04/06/2022 at 08:00 p.m. when nursing staff failed to administer her second scheduled daily dose of [MEDICATION(S)] 24/26 mg, which was prescribed to treat a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon return to the facility on [DATE], nursing staff continued to omit the second daily dose of [MEDICATION(S)]. This deficient practice resulted in an Immediate Jeopardy situation for Resident #9 beginning on 04/08/2022 upon admission to the facility when nursing staff failed to accurately transcribe admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in multiple medication errors for Resident #9 from 04/08/2022 through 05/05/2022. In addition, Resident #9 did not consistently receive monitoring of blood glucose levels or administration of correct doses or type of insulin for multiple missed and/or inaccurate opportunities. These errors resulted in Resident #9 being transferred to the emergency roiagnom on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon return to the facility on [DATE], the medication errors, inconsistent monitoring of blood glucose levels and inconsistent administration of hyperglycemic medications continued. S1ADM was notified of the immediate jeopardy on 05/06/2022 at 01:10 p.m. The Immediate Jeopardy was removed on 05/06/2022 at 03:25 p.m. when the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: Affected Residents - Action Taken Facility reviewed physicians' orders and verified accuracy with the provider, then reviewed the Medication Administration Record for Residents # 1 and #9 and ensured that orders were accurate and matched what was transcribed to the residents' Medication Administration Record. Facility then reviewed medication on cart and ensured that the medication cards matched the orders and were available and being administered correctly. Facility DON or designee then observed monitoring of current blood glucose level. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. The DON and designee(s) completed a chart audit of all residents receiving medication for pain management, diabetes mellitus, and cardiac related diagnoses. The Medication Administration Records (MAR) were reviewed against the physicians' orders to ensure transcription accuracy, medications timely acquired, documented appropriately, and administered as ordered. (Initiated 05/04/2022 at 08:00 p.m.) I Anticipated Completion Date 05/09/2022) - Any negative findings will be corrected immediately and DON/Designee Notified. The DON and Nursing Administrative staff completed a chart audit of residents with diabetes mellitus requiring blood glucose monitoring and insulin were reviewed to ensure accurate administration of insulin as ordered. (Initiated 05/04/2022 at 08:00 p.m. Anticipated Completion Date 05/09/2022) - Any negative findings will be corrected immediately and DON/Designee Notified. The DON and Nursing Administrative staff completed a review of narcotic medication counts against the MAR and medication card to ensure accurate documentation and procedures as outlined in the facility's Controlled Substance and Accountability Policy. (Initiated 50/04/2022 at 08:00 p.m. Anticipated Completion Date 05/09/2022) - Any negative findings will be corrected immediately and DON/Designee Notified. The Facility Medical Director or Nurse Practitioner will review all residents' current and active orders to determine accuracy. (Initiated 05/6/2022. Anticipated Completion Date 05/13/2022) Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. All applicable facility policies and procedures were reviewed by the DON or designee. (Completed 05/05/2022) Facility DON and ADON will receive education on monitoring and implementation of routine chart audits including Physicians Orders, Medication Administration Record, Narcotic Logs, Signs/Symptoms of Heart Failure and Uncontrolled Diabetes, Documentation and Transcription or Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Initiated 05/05/2022. Anticipated Completion Date 05/06/2022) The DON or designee re-educated licensed nurses on facility policies regarding the following facility's policies and all nurses were educated prior to working their next shift: (Initiated 05/04/2022 at 08:00 p.m., All licensed nurses must receive education prior to shift) Medication Administration Policy Medication Error Policy Medication Monitoring Policy Unavailable Medications Policy Medication Reordering Policy Timely Administration of Insulin Policy Blood Glucose Monitoring Policy Controlled Substance Administration and Accountability Policy Signs/Symptoms of Heart Failure & Uncontrolled Diabetes Documentation and Transcription of Physician Orders Facility Pharmacy Consultant, Corporate QA Nurse, and Representatives from Pharmacy will be on hand to conduct a mandatory in person in-service with licensed nurses on Wednesday, May 11th at 02:00 p.m. A competency exam will be administered at the conclusion of this training and licensed nurses must prove knowledge by obtaining a pass rate of 90% or above on the exam. Any licensed nurse that does not attend mandatory in-service must review education materials provided during the training and complete exam with a pass rate of 90% or above before working any future shift. The DON or designee will monitor appropriate implementation by reviewing MAR's Narcotic Logs, and new orders during clinical startup meeting to confirm transcription accuracy. (Initiated 05/05/2022 - Any negative findings will be corrected immediately) Will continue monitoring 5 x week for 2 weeks, 3 x week for 2 weeks, and 1 x week for 4 weeks. Facility DON or designee will review all new admission charts and MAR's to confirm transcription of orders is accurate. (Initiated 05/06/2022) - Any negative findings will be corrected immediately and DON/Designee Notified. The DON will complete corrective action and one-to-one education on above listed topics with licensed nurse(s) identified as being deficient in their practice resulting in this citation. (Initiated 05/05/2022) The DON or designee will educate and supervise all current and new hire licensed nurses and agency nurses on the above policies and ensure adequate training and are competent to provide appropriate care to residents according to their plan of care and facility's policies. (Initiated 05/05/2022) The DON or designee will conduct weekly chart audits for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The audits will continue until compliance can be maintained for 3 consecutive months. (Initiated 05/05/2022) Will continue monitoring 5 x week for 2 weeks, 3 x week for 2 weeks, and 1 x week for 4 weeks. The DON and Nursing Administrative staff completed a chart audit of residents with diabetes mellitus requiring blood glucose monitoring and insulin were reviewed to ensure accurate administration of insulin as ordered. (Initiated 05/04/2022) Will continue monitoring 5 x week for 2 weeks, 3 x week for 2 weeks, and 1 x week for 4 weeks. The DON or designee will conduct a medication cross match weekly to identify the amount on hand is checked against the amount used daily from the documentation records of Controlled Substance Count and MAR. (Initiated 05/05/2022) Will continue monitoring 5 x week for 2 weeks, 3 x week for 2 weeks, and 1 x week for 4 weeks. The DON and designees will complete match back of all medication carts and ensure accurate medications are on hand for all current orders. (Will initiate immediately upon completion of Physicians Order review being conducted by Facility Medical Director/Nurse Practitioners) The deficient practice continued at a potential for more than minimal harm for all of the 117 residents that remained in the facility who received medications administered by the nursing staff. Findings: Review of the Pharmacy Service Agreement revealed the following, in part: Emergency Services Facility shall have available Emergency pharmaceutical services twenty four hours per day, seven days per week in their Facility stock. Review of the Policy Titled, Medication Orders revealed the following, in part: Policy: This facility shall use uniform guidelines for the ordering of medication. 1. Medications should be administered only upon the signed order of a person lawfully authorized to prescribe. 2. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. (See Verbal Orders Policy) Documentation of Medication Orders: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] b. Clarify the order. c. Enter the order on the medication order and receipt record d. Call or fax the medication order to the provider pharmacy. e. Transcribe newly prescribed medications on the MAR or treatment record. f. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd and the date. g. Enter the new order on the MAR. h. Notify resident's sponsor/family of new medication order. Specific Procedures for Medication Orders: i. Handwritten Order Signed by the Physician - The charge nurse on duty at the time the order is received should note the order and enter it on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If necessary, the order should be clarified before the physician leaves the nursing station, whenever possible, j. Verbal Orders - The nurse should document an order by telephone or in person on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . k. Written Transfer Orders - (sent with a resident by a hospital or other health care facility) Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending, before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Example: Order verified by the phone with Dr. Smith/M. Jones, R.N. Review of the Policy Titled, Medication Administration revealed the following, in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign narcotic book. Medication timing (excludes insulin): a. BID 09:00 a.m., 09:00 p.m. Review of the Policy Titled, Medication Orders revealed the following, in part: 1. Documentation of medication orders a. The order should be recorded on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] e. Transcribe newly prescribed medications on the MAR or treatment record. Review of the Policy Titled, Pain Management revealed the following, in part: Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: b. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body, or guarding a limb or other body parts) c. Fidgeting, increased or recurring restlessness d. Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw) e. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming) 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information as applicable to the resident: a. History of pain and its treatment including non-pharmacological, pharmacological, and alternative medicine treatment and whether or not each treatment has been effective; b. Reviewing the resident's current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post [CONDITION(S)], venous and arterial ulcers, and multiple [CONDITION(S)]). g. Impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood). h. Current prescribed pain medications, dosage and frequency. Pain Management and Treatment: 2. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. Review of the policy titled, Timely Administration of Insulin revealed the following, in part: Policy: It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition Policy Explanation and Compliance Guidelines: 1. All insulin will be administered in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. For current insulin orders, an adequate supply of insulin will be maintained for each resident. Insulin will be reordered as needed according to facility policy. 3. For new or emergency orders for insulin, the facility may use medications from the emergency kit. 4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order. Procedure: a. Review the insulin order: Resident name. ii. Medication name. iii. Medication dosage. iv. Time to be administered. v. Route of administration. b. Timely Administration of Insulin. b. Prepare insulin dose. Before administering insulin, perform two nurse verification of correct resident, dose calculations, and correct route of administration. c. Administer insulin at appropriate times. d. Document on the medication administration record the time and location of the insulin injection. Review of the Facility's Standing Orders revealed the following, in part: 10. Diabetes a. Accuchecks AC and HS if patient is on insulin and not specified. c. Sliding scale with regular insulin given subcutaneously: Less than 60 - Give juice and call provider. Check Less than 200 - no coverage 200 to 250 - 4 units 251 to 300 - 6 units 301 to 350 - 8 units 351 to 400 - 10 units 401 to 450 - 12 units Greater than 450 - 14 units Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses, which included Unspecified [CONDITION(S)], Unspecified [CONDITION(S)] Flutter, Hypertension, and Congestive Heart Failure. Review of the quarterly MDS with an ARD of 03/15/2022 revealed Resident #1 had a BIMS of 15, which indicated the resident was cognitively intact. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] (Start date: 04/05/2022) [MEDICATION(S)] 24/26 milligrams by mouth twice daily Review of Resident #1's hospital lab results dated 04/04/2022 revealed: B-Natriuretic Peptide: 1014.9 pg/mL - High. (Normal range is 0.0-99.9 pg/mL. BNP levels go up when the heart cannot pump the way it should. The higher the number, the more likely heart failure is present and the more severe it is.) Review of the Pharmacy Refill Log for Resident #1 for April 2022 revealed the following, in part: Drug/Description: [MEDICATION(S)] 24-26 milligram tablet, one tablet by mouth twice daily. Fill dates and quantities sent to the facility: 04/05/2022 - 18 tablets, 04/12/2022 - 28 tablets, and 04/27/2022 - 28 tablets Review of the current Care Plan for Resident #1 revealed the following, in part: Problem: [CONDITION(S)] and [CONDITION(S)] Flutter - risk for irregular pulse and chest pains secondary to history of [CONDITION(S)]/[CONDITION(S)] Flutter rhythm. Intervention: Medications as ordered by the Medical Doctor. Problem: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: I will not experience chest pain and pulse will remain within normal limits through next review period. Interventions: Medications as ordered. Obtain labs as ordered and report abnormal findings to my Medical Doctor promptly. Alert my Medical Doctor to any signs/symptoms if resident with any verbal complaint of chest pain, numbness, dizziness, and treat as indicated. Assess me for any [CONDITION(S)] or fluid buildup in lungs and report to my Medical Doctor as needed. Review of the Medication Administration Record dated April 2022 for Resident #1 revealed the following, in part: [MEDICATION(S)] 24/26 milligrams by mouth twice daily; signatures on 04/06/2022 through 04/27/2022 at 08:00 a.m. which indicated Resident #1 received the medication. No documentation Resident #1 received [MEDICATION(S)] twice daily. Review of the Transfer Log dated April 2022 revealed the following entry for Resident #1: Date/time of transfer: 04/22/2022 at 04:30 p.m. Reason for transfer: chest pain Return date/time: 04/23/2022 at 05:00 a.m. Review of the hospital records for Resident #1 dated 04/22/2022 revealed the following, in part: History and Physical Summary: 04/22/2022 at 05:20 p.m., Resident #1 presented with chest pain. She described her pain as burning to the center of her lower chest with occasional sharp pains. She had some pain under her right breast and the burning occurred more when lying down. She had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical Exam: Chest: positive tenderness to palpitation, regular rate and rhythm, positive non-pitting [CONDITION(S)] to left lower extremity. Review of Resident #1's hospital lab results dated 04/04/2022 revealed: B-Natriuretic Peptide: 1014.9 pg/mL - High. (Normal range is 0.0-99.9 pg/mL. BNP levels go up when the heart cannot pump the way it should. The higher the number, the more likely heart failure is present and the more severe it is.) Review of Resident #1's radiology report dated 04/22/2022 at 07:42 p.m. revealed: Chest x-ray portable Impression: possible mild Congestive Heart Failure with interstitial [CONDITION(S)] versus developing pneumonia noting consolidative changes in right lower lung. Recommend clinical correlation and continued follow up. Electrocardiogram: Result: abnormal, current rhythm- [CONDITION(S)], non-specific ST abnormality Review of Resident #1's hospital Medication Administration Record dated 04/22/2022 revealed: Medication: Immediately, [MEDICATION(S)] 10 milligrams/milliliter, Parental solution Dose: 10 milligrams/4 milliliters Administered 04/22/2022 at 09:08 p.m. Review of Resident #1's hospital Discharge Summary dated 04/23/2022 at 04:09 a.m. revealed: diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical exam was notable for irregularly irregular heartbeat, mild tenderness to epigastrium, and left lower extremity [CONDITION(S)]. Resident #1's chest X-Ray demonstrated infiltrates consistent with Mild Exacerbation of Congestive Heart Failure. Resident #1 was given an additional dose of [MEDICATION(S)] in the emergency room and instructed to follow-up with her primary care provider and cardiologist as soon as possible. A telephone interview was conducted with S6PHARM on 04/29/2022 at 10:27 a.m. She stated Resident #1's [MEDICATION(S)] 24/26 milligrams was filled on 04/05/2022. She verified the following quantities were sent to the facility: 04/05/2022 - quantity: 18, 04/12/2022 - quantity: 28, and 04/27/2022 - quantity: 28 An observation was made with S7LPN of Resident #1's medication cards on 04/29/2022 at 11:20 a.m. The following was observed: [MEDICATION(S)] 24/26 milligrams dated 04/14/2022 - 19 pills present and [MEDICATION(S)] 24/26 milligrams dated 04/27/2022 - 27 pills present An interview was conducted with Resident #1 on 04/29/2022 at 11:53 a.m. She stated she received [MEDICATION(S)] once daily in the mornings. She confirmed she had never received [MEDICATION(S)] twice daily. An interview was conducted with S2DON on 04/29/2022 at 01:22 p.m. He verified Resident #1 had only received [MEDICATION(S)] once daily since 04/06/2022 and she should have received it twice daily. He stated the nurse who transcribed the order should have put a morning and evening/night dose time slot on Resident #1's Medication Administration Record to prompt the night nurse to administer the medication again. He verified Resident #1 had only received [MEDICATION(S)] once daily based on the amount available in the medication cards compared to the amount received by the pharmacy. He confirmed Resident #1's emergency room visit on 04/22/2022 could have been avoided if she had received [MEDICATION(S)] twice daily. He also confirmed after Resident #1 returned to the facility from the emergency room the nursing staff failed to begin to administer [MEDICATION(S)] twice daily as ordered. An interview was conducted with Resident #1's cardiologist on 05/04/2022 at 09:12 a.m. The physician confirmed Resident #1 should have been receiving [MEDICATION(S)] daily for [CONDITION(S)]. The physician stated Resident #1 was at increased risk for stroke related to her [CONDITION(S)], and if she had not received all doses of her Xarleto, she was at a greater increased risk of stroke. The physician confirmed Resident #1 should have been receiving [MEDICATION(S)] twice daily for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician stated [MEDICATION(S)] was to help decrease [CONDITION(S)] and Congestive Heart Failure Exacerbations. An interview was conducted with S7LPN on 05/04/2022 at 11:30 a.m. She stated when she received a new medication order, she placed the new order on the Medication Administration Record, and she would place 08:00 a.m. and 08:00 p.m. on the hour slot if it was a twice daily medication. She verified the Medication Administration Record for Resident #1 dated April 2022 only had an 08:00 a.m. time slot. She stated the nurse would not know to administer a second dose in the evening unless she read the drug description. She verified the [MEDICATION(S)] medication order read twice daily but there were no signatures present to indicate Resident #1 received an evening dose since the start of the medication order on 04/05/2022. A telephone interview was conducted with S10LPN on 05/06/2022 at 01:40 p.m. She verified she was assigned to care for Resident #1 from 02:00 p.m. to 10:00 p.m. on 04/22/2022. She confirmed Resident #1 complained of burning chest pain on 04/22/2022. She stated she assessed Resident #1 and immediately notified S11NP who ordered Resident #1 be transferred to the emergency room . An interview was conducted with S13CNA on 05/06/2022 at 02:04 p.m. She stated on 04/22/2022 around 04:30 p.m., Resident #1 was in the dining room complaining of chest pain. She stated her and the nurse immediately brought Resident #1 to her room and the nurse assessed her. She stated Resident #1 was assisted to bed and an ambulance picked her up from the facility. An interview was conducted with S11NP on 05/06/2022 at 02:20 p.m. She verified she was in the facility on 04/22/2022 when Resident #1 complained of chest pain. She stated she was asked by S10LPN to assess Resident #1. She stated Resident #1 complained of shortness of breath and burning chest pain. She stated she gave an order to send Resident #1 to the hospital. Resident #9 Review of the clinical record revealed Resident # 9 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS with an ARD of 04/15/2022 revealed Resident # 9 had a BIMS of 14, which indicate he was cognitively intact. Review of Hospital Records revealed resident was discharged to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Hospital Records revealed resident was sent out to the local emergency department on 05/04/2022 for a capillary blood glucose reading of 600. Resident #9 reported to hospital staff that he had missed 2 doses of [MEDICATION(S)] in the last week because the medication was not available. He received treatment in the Emergency Department for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital's Physician Discharge Orders, dated 04/08/2022, revealed in part, the following: New medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (Insulin [MEDICATION(S)]) 100 unit/mL - Inject (Inj) 4 units into the skin three times daily before meals. [MEDICATION(S)] Solustar U-100 Insulin 100 unit/mL - Inj 14 units into the skin nightly. [MEDICATION(S)] Powder - Topical twice daily. Medications to Continue: Blood Glucose Meter - Four times daily, before meals and nightly (ACHS). [MEDICATION(S)] [MEDICATION(S)] (Insulin [MEDICATION(S)]) U-100 Insulin 100 unit/mL - Inj 3 units into the skin 3 times daily with meals (08:00 a.m., 11:30 a.m., 05:30 p.m.) Review of the current Care Plan for Resident # 9 revealed the following, in part: Problem: I am at risk for elevated blood glucose levels related to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Intervention: Monitor blood sugar as ordered. Administer medications as ordered. Review of the Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] No order written for [MEDICATION(S)] Inj per sliding scale (SS) with accuchecks three times daily. (Sliding Scale: 0-200 = 0 units, 200-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, 401-450 = 12 units, >450 = 14 units and notify MD/NP). No order written for [MEDICATION(S)] Powder topically twice daily. Review of the May 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] No order written for [MEDICATION(S)] per sliding scale (SS) with accuchecks three daily. (Sliding Scale: 0-200 = 0 units, 200-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, 401-450 = 12 units, >450 = 14 units and notify MD/NP). Review of the Medication Administration Record (MAR), April 2022, revealed, the following, in part: [MEDICATION(S)] Powder - Topically twice daily. (Not present on MAR): 0 of 44 doses with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 04/08/2022 through 04/30/2022 at 08:00 a.m.; and 04/08/2022 through 04/30/2022 at 05:00 p.m. [MEDICATION(S)] [MEDICATION(S)] - 1 tab by mouth daily: 22 doses without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 04/08/2022 through 04/30/2022 at 08:00 a.m. [MEDICATION(S)] R U-100 - SubQ per SS ACHS: 88 doses without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 04/08/2022 through 04/30/2022 at 05:30 a.m.; 04/08/2022 through 04/30/2022 at 11:30 a.m.; 04/08/2022 through 04/30/2022 at 04:00 p.m.; and 04/08/2022 through 04/30/2022 at 08:00 p.m. Review of the printed Medication Administration Record (MAR), dated 05/01/2022 and in use through 05/05/2022 at noon, revealed, in part, the following [MEDICATION(S)] [MEDICATION(S)] - 1 tab by mouth daily: 4 doses without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 05/01/2022 through 05/04/2022 at 08:00 a.m. [MEDICATION(S)] R U-100 - SubQ per SS ACHS: 18 doses without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 05/01/2022 through 05/05/2022 at 05:30 a.m.; 05/01/2022 through 05/05/2022 at 11:30 a.m.; 05/01/2022 through 05/05/2022 at 04:00 p.m.; and 05/01/2022 through 05/05/2022 at 08:00 p.m. Review of the Medication Administration Record (MAR), dated April 2022 through May 05, 2022, revealed, in part, the following: [MEDICATION(S)] 14 units SubQ nightly at 08:00 p.m.: the fo

Based on observations, interviews and record reviews the facility failed to ensure residents were free of significant medication errors for 2 (#1, #9) of 13 (1#, #2, #3, #6, #8, #9, #12, R1, R4, R5, R6, R7, R8) residents observed during medication pass. The facility failed to ensure: 1. Resident #1 received cardiac medications as ordered by the physician; and 2. Resident #9 received blood glucose monitoring and insulins as ordered by the physician. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 beginning on 04/06/2022 at 08:00 p.m. when nursing staff failed to administer her second scheduled daily dose of [MEDICATION(S)] 24/26 mg, which was prescribed to treat a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 did not receive the second daily dose of [MEDICATION(S)] from 04/06/2022 through 04/22/2022 resulting in being transferred to the emergency room and diagnosed with a [CONDITION(S)] Exacerbation. Upon return to the facility on [DATE], nursing staff continued to omit the second daily dose of [MEDICATION(S)]. This deficient practice resulted in an Immediate Jeopardy situation for Resident #9 beginning on 04/08/2022 upon admission to the facility when nursing staff failed to accurately transcribe medication orders onto his MAR. The transcription errors led to the administration of the wrong type and frequency of insulin. This resulted in multiple medication errors for Resident #9 from 04/08/2022 through 05/05/2022. In addition, Resident #9 did not consistently receive monitoring of blood glucose levels or administration of correct doses or type of insulin for multiple missed and/or inaccurate opportunities. These errors resulted in Resident #9 being transferred to the emergency roiagnom on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon return to the facility on [DATE], the medication errors, inconsistent monitoring of blood glucose levels and inconsistent administration of hyperglycemic medications continued. S1ADM and S2DON were notified of the Immediate Jeopardy on 05/04/2022 at 07:00 p.m. The Immediate Jeopardy was removed on 05/06/2022 at 03:25 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record reviews surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: Identification of Residents affected or likely to be affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. The DON and designee(s) completed a chart audit of all residents receiving medication for pain management, diabetes mellitus, and cardiac related diagnoses. The Medication Administration Records (MAR) were reviewed against the physicians' orders to ensure transcription accuracy, medications timely acquired, documented appropriately, and administered as ordered. (Initiated 05/04/2022 at 08:00 p.m. Anticipated Completion Date 05/09/2022) - Any negative findings will be corrected immediately and DON/Designee notified. The DON and Nursing Administrative staff completed a chart audit of residents with Diabetes Mellitus requiring blood glucose monitoring and insulin were reviewed to ensure accurate administration of insulin as ordered. (Initiated on 05/04/2022 at 08:00 p.m. with an anticipated completion date 05/09/2022 - Any negative findings will be corrected immediately and DON/Designee notified. The DON and Nursing Administrative staff completed a review of narcotic medication counts against the MAR and medication card to ensure accurate documentation and procedures as outlined in the facility's Controlled Substance and Accountability Policy. (Initiated 05/04/2022 at 08:00 p.m. anticipated completion date 05/09/2022) - Any negative findings will be corrected immediately and DON/Designee notified. The Facility Medical Director or Nurse Practitioner will review all residents' current and active orders to determine accuracy. (Initiated 05/06/2022 anticipated completion date 05/13/2022) Actions to prevent occurrence/recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. The DON or designee reviewed all applicable facility policies and procedures. (Completed 05/05/2022) Facility DON and ADON will receive education on monitoring and implementation of routine chart audits including Physicians Orders, Medication Administration Record, and Narcotic Logs from the Corporate QA Nurse. Competency will be verified by exam and a pass rate of 90% or higher must be achieved. (Initiated 05/05/2022 - anticipated completion date 05/06/2022) The DON or designee re-educated licensed nurses prior to working their next shift on the following facility's policies: (Initiated 05/04/2022 at 08:00 p.m., All Licensed Nurses must receive education prior to shift) Medication Administration Policy Medication Error Policy Medication Monitoring Policy Unavailable Medications Policy Medication Reordering Policy Timely Administration of Insulin Policy Blood Glucose Monitoring Policy Controlled Substance Administration and Accountability Policy Facility Pharmacy Consultant, Corporate QA Nurse, and Representatives from Pharmacy will conduct a mandatory in person in-service with licensed nurses on Wednesday, May 11 at 2:00 p.m. A competency exam will be administered at the conclusion of this training and licensed nurses must prove knowledge by obtaining a pass rate of 90% or above on the exam. Any licensed nurse that does not attend mandatory in service must review education materials provided during the training and complete exam with a pass rate of 90% or above before working any future shift. The DON or designee will monitor appropriate implementation by reviewing MAR's, Narcotic Logs, and new orders during clinical startup meeting. (Initiated 05/05/2022 - Any negative findings will be corrected immediately) The DON will complete corrective action and one-to-one education on above listed topics with licensed nurse(s) identified as being deficient in their practice resulting in this citation. (Initiated 05/05/2022) The DON or designee will educate and supervise all current and new hire licensed nurses and agency nurses on the above policies, ensure adequate training, and are competent to provide appropriate care to residents according to their plan of care and facility's policies. (Initiated 05/05/2022) The DON or designee will conduct weekly chart audits for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The audits will continue until compliance can be maintained for three consecutive months. (Initiated 05/05/2022) The DON and Nursing Administrative staff completed a chart audit of residents with diabetes mellitus requiring blood glucose monitoring and insulin were reviewed to ensure accurate administration of insulin as ordered. (Initiated 05/04/2022) The DON or designee will conduct a medication cross match weekly to identify the amount on hand is checked against the amount used daily from the documentation records of Controlled Substance Count and MAR. (Initiated 05/05/2022) The DON and designees will complete match back of all medication carts and ensure accurate medications are on hand for all current orders. (Will initiate immediately upon completion of physicians order review being conducted by facility Medical Director/Nurse Practitioners) The deficient practice continued at a potential for more than minimal harm for all of the 117 residents residing in the facility who received medications administered by the nursing staff. Findings: Review of the Medication Administration policy revealed the following, in part: Policy Medication are to be administered as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines 3. Identify resident by photo in the MAR 8. Obtain and record vitals sings when applicable or per physicians orders. 10. Review MAR to identify medication to be administered. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. 17. Sign MAR after administered. 18. If medication is a controlled substance, sign the narcotic book. 20. Correct any discrepancies and report to the nurse manager. Review of the Facility's Standing Orders revealed the following, in part: 10. Diabetes a. Accuchecks AC and HS if patient is on insulin and not specified. c. Sliding scale with regular insulin given subcutaneously: Less than 60 - Give juice and call provider. Check Less than 200 - no coverage 200 to 250 - 4 units 251 to 300 - 6 units 301 to 350 - 8 units 351 to 400 - 10 units 401 to 450 - 12 units Greater than 450 - 14 units Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS with an ARD of 03/15/2022 revealed Resident #1 had a BIMS of 15, which indicated the resident was cognitively intact. Review of the current Care Plan for Resident #1 revealed the following, in part: Problem: [CONDITION(S)] and [CONDITION(S)] Flutter - risk for irregular pulse and chest pains secondary to history of [CONDITION(S)]/[CONDITION(S)] Flutter rhythm. Intervention: Medications as ordered by the Medical Doctor. Problem: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . My nurse monitors me for any complications and reports to my Medical Doctor as appropriate. Goal: I will not experience chest pain and pulse will remain within normal limits through next review period. Interventions: Medications as ordered. Obtain labs as ordered and report abnormal findings to my Medical Doctor promptly. Alert my Medical Doctor to any signs/symptoms if resident with any verbal complaint of chest pain, numbness, dizziness, and treat as indicated. Assess me for any [CONDITION(S)] or fluid buildup in lungs and report to my Medical Doctor as needed. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] (Start date: 04/05/2022) [MEDICATION(S)] 24/26 milligrams by mouth twice daily (Start date: 04/05/2022) [MEDICATION(S)] 20 milligrams by mouth daily Review of the Pharmacy Refill Log for Resident #1 for April 2022 revealed the following, in part: Drug/Description: [MEDICATION(S)] 24-26 milligram tablet, one tablet by mouth twice daily. Fill dates and quantities sent to the facility: 04/05/2022 - 18 tablets, 04/12/2022 - 28 tablets, and 04/27/2022 - 28 tablets Drug/Description: [MEDICATION(S)] 20 milligram tablet by mouth daily Fill dates and quantities filled: 04/05/2022 - 9 tablets, 04/12/2022 - 14 tablets, and 04/27/2022 - 14 tablets Review of the Medication Administration Record dated April 2022 for Resident #1 revealed the following, in part: [MEDICATION(S)] 24/26 milligrams by mouth twice daily; missing signatures on 04/06/2022 through 04/27/2022 for the evening dose indicated Resident #1 did not receive [MEDICATION(S)] twice daily as ordered [MEDICATION(S)] 20 milligrams by mouth daily at 08:00 a.m.; missing signatures on 04/14/2022 and 04/22/2022, which indicated Resident #1 did not receive it. A telephone interview was conducted with S6PHARM on 04/29/2022 at 10:27 a.m. She stated Resident #1's [MEDICATION(S)] 24/26 milligrams was filled on 04/05/2022. She verified the following quantities were sent to the facility: 04/05/2022 - quantity: 18, 04/12/2022 - quantity: 28, and 04/27/2022 - quantity: 28 [MEDICATION(S)] 20 milligrams and delivered to the facility: 04/05/2022 - quantity: 9, 04/12/2022 - quantity: 14, and 04/27/2022 - quantity: 14 An observation was made of Resident #1's Xarleto 20 milligram tablets medication card on 04/28/2022 at 02:30 p.m. with S5LPN. S5LPN confirmed Resident #1 had one card of [MEDICATION(S)] 20 milligram tablets that was dated 04/14/2022 and had 4 tablets left and a medication card of [MEDICATION(S)] 20 milligram tablets dated 04/27/2022 that contained 14 pills. An observation was made with SS7LPN of Resident #1's medication cards on 04/29/2022 at 11:20 a.m. The following was observed: [MEDICATION(S)] 24/26 milligrams dated 04/14/2022 - 19 pills present and [MEDICATION(S)] 24/26 milligrams dated 04/27/2022 - 27 pills present An interview was conducted with Resident #1 on 04/29/2022 at 11:53 a.m. She stated she received [MEDICATION(S)] once daily in the mornings. She confirmed she had never received [MEDICATION(S)] twice daily. An interview was conducted with S2DON on 04/29/2022 at 01:22 p.m. S2DON confirmed that Resident #1 should have been out of her [MEDICATION(S)] that was filled on 04/12/2022. He confirmed there were three missed dosed of [MEDICATION(S)]. He verified Resident #1 had only received [MEDICATION(S)] once daily since 04/06/2022 and she should have received it twice daily. He stated the nurse who transcribed the order should have put a morning and evening/night dose time slot on Resident #1's Medication Administration Record to prompt the night nurse to administer the medication again. He verified Resident #1 had only received [MEDICATION(S)] once daily based on the amount available in the medication cards compared to the amount received by the pharmacy. He confirmed Resident #1's emergency room visit on 04/22/2022 could have been avoided if she had received [MEDICATION(S)] twice daily. He also confirmed after Resident #1 returned to the facility from the emergency room the nursing staff failed to begin to administer [MEDICATION(S)] twice daily as ordered. An interview was conducted with S7LPN on 05/04/2022 at 11:30 a.m. She stated when she received a new medication order, she placed the new order on the Medication Administration Record, and she would place 08:00 a.m. and 08:00 p.m. on the hour slot if it was a twice daily medication. She verified the Medication Administration Record for Resident #1 dated April 2022 only had an 08:00 a.m. time slot. She stated the nurse would not know to administer a second dose in the evening unless she read the drug description. She verified the [MEDICATION(S)] medication order read twice daily but there were no signatures present to indicate Resident #1 received an evening dose since the start of the medication order on 04/05/2022. A telephone interview was conducted with S10LPN on 05/06/2022 at 01:40 p.m. She verified she was assigned to care for Resident #1 from 02:00 p.m. to 10:00 p.m. on 04/22/2022. She confirmed Resident #1 complained of burning chest pain on 04/22/2022. She stated she assessed Resident #1 and immediately notified S11NP who ordered Resident #1 be transferred to the emergency room . An interview was conducted with S13CNA on 05/06/2022 at 02:04 p.m. She stated on 04/22/2022 around 04:30 p.m., Resident #1 was in the dining room complaining of chest pain. She stated her and the nurse immediately brought Resident #1 to her room and the nurse assessed her. She stated Resident #1 was assisted to bed and an ambulance picked her up from the facility. An interview was conducted with S11NP on 05/06/2022 at 02:20 p.m. She verified she was in the facility on 04/22/2022 when Resident #1 complained of chest pain. She stated she was asked by S10LPN to assess Resident #1. She stated Resident #1 complained of shortness of breath and burning chest pain. She stated she gave an order to send Resident #1 to the hospital. Review of the Transfer Log dated April 2022 revealed Resident #1was transferred to the hospital on 04/22/2022 at 04:30 p.m. with Review of hospital records revealed Resident #1 arrived at the hospital on 04/22/2022 at 05:20 p.m. with chest pain. She described her pain as burning to the center of her lower chest with occasional sharp pains. She had some pain under her right breast and the burning occurred more when lying down. She had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical exam was notable for irregularly irregular heartbeat, mild tenderness to epigastrium, and left lower extremity [CONDITION(S)]. Resident #1's chest xray demonstrated infiltrates consistent with Mild Exacerbation of [CONDITION(S)]. Resident #1's Electrocardiogram revealed the resident was in [CONDITION(S)]. Resident #1 was given an additional dose of [MEDICATION(S)] in the emergency room and instructed to follow-up with her primary care provider and cardiologist as soon as possible. Review of Resident #1's hospital lab results dated 04/22/2022 revealed: B-Natriuretic Peptide: 790.5 pg/mL - High. (Normal range is 0.0-99.9 pg/mL. BNP levels go up when the heart cannot pump the way it should. The higher the number, the more likely heart failure is present and the more severe it is.) An interview was conducted with Resident #1's cardiologist on 05/04/2022 at 09:12 a.m. The physician confirmed Resident #1 should have been receiving [MEDICATION(S)] daily for [CONDITION(S)]. The physician stated Resident #1 was at increased risk for stroke related to her [CONDITION(S)], and if she had not received all doses of her Xarleto, she was at a greater increased risk of stroke. The physician confirmed Resident #1 should have been receiving [MEDICATION(S)] twice daily for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician stated Resident #1's emergency room visit on 04/22/2022 could have been prevented if she had received the [MEDICATION(S)] twice daily. The physician stated [MEDICATION(S)] was to help decrease [CONDITION(S)] and [CONDITION(S)] Exacerbations. Resident #9 Review of the clinical record revealed Resident # 9 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS with an ARD of 04/15/2022 revealed Resident # 9 had a BIMS of 14, which indicate he was cognitively intact. Review of Hospital Records revealed resident was discharged to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Hospital Records revealed resident was sent out to the local emergency department on 05/04/2022 for a capillary blood glucose reading of 600. Resident #9 reported to hospital staff that he had missed 2 doses of [MEDICATION(S)] in the last week because the medication was not available. He received treatment in the Emergency Department for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital Physician Discharge Orders, dated 04/08/2022, revealed in part, the following: New medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (Insulin [MEDICATION(S)]) 100 unit/mL - Inject (Inj) 4 units into the skin three times daily before meals. [MEDICATION(S)] Solustar U-100 Insulin 100 unit/mL - Inj 14 units into the skin nightly. Medications to Continue: Blood Glucose Meter - Four times daily, before meals and nightly (ACHS). [MEDICATION(S)] [MEDICATION(S)] (Insulin [MEDICATION(S)]) U-100 Insulin 100 unit/mL - Inj 3 units into the skin 3 times daily with meals (08:00 a.m., 11:30 a.m., 05:30 p.m.) Review of the current Care Plan for Resident # 9 revealed the following, in part: Problem: I am at risk for elevated blood glucose levels related to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Intervention: Monitor blood sugar as ordered. Administer medications as ordered. Review of the Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] No order written for [MEDICATION(S)] Inj per sliding scale (SS) with accuchecks three times daily. (Sliding Scale: 0-200 = 0 units, 200-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, 401-450 = 12 units, >450 = 14 units and notify MD/NP). Review of the May 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] No order written for [MEDICATION(S)] per sliding scale (SS) with accuchecks three daily. (Sliding Scale: 0-200 = 0 units, 200-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, 401-450 = 12 units, >450 = 14 units and notify MD/NP). Review of the Medication Administration Record (MAR), April 2022, revealed, the following, in part: [MEDICATION(S)] R U-100 - SubQ per SS ACHS: 88 doses without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 04/08/2022 through 04/30/2022 at 05:30 a.m.; 04/08/2022 through 04/30/2022 at 11:30 a.m.; 04/08/2022 through 04/30/2022 at 04:00 p.m.; and 04/08/2022 through 04/30/2022 at 08:00 p.m. Review of the printed Medication Administration Record (MAR), dated 05/01/2022 and in use through 05/05/2022 at noon, revealed, in part, the following [MEDICATION(S)] R U-100 - SubQ per SS ACHS: 18 doses without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 05/01/2022 through 05/05/2022 at 05:30 a.m.; 05/01/2022 through 05/05/2022 at 11:30 a.m.; 05/01/2022 through 05/05/2022 at 04:00 p.m.; and 05/01/2022 through 05/05/2022 at 08:00 p.m. Review of the Medication Administration Record (MAR), dated April 2022 through May 05, 2022, revealed, in part, the following: [MEDICATION(S)] 14 units SubQ nightly at 08:00 p.m.: the following possible doses were not documented on the following dates/times: 04/14/2022; 04/15/2022; 04/18/2022; 04/22/2022; 04/27/2022; 04/28/2022; 04/29/2022; and 05/04/2022. [MEDICATION(S)] 3 units SubQ three times daily with meals at 08:00 a.m., 11:00 a.m. and 05:00 p.m.: the following possible doses were not documented on the following dates/times: 04/15/2022 at 05:00 p.m.; 04/19/2022 at 08:00 a.m.; 04/22/2022 at 05:00 p.m.; 04/23/2022 at 08:00 a.m.; 04/28/2022 at 08:00 a.m.; 04/29/2022 at 08:00 a.m.; 04/29/2022 at 11:00 a.m.; 04/29/2022 at 05:00 p.m.; 04/30/2022 at 08:00 a.m.; 04/30/2022 at 11:00 a.m.; and 04/30/2022 at 05:00 p.m. Insulin - SubQ per SS ACHS: the following possible doses were not documented on the following dates/times: 04/24/2022 at 08:00 p.m.; 04/26/2022 at 04:00 p.m.; 04/26/2022 at 08:00 p.m.; 04/27/2022 at 04:00 p.m.; 04/28/2022 at 08:00 p.m.; 04/29/2022 at 11:00 a.m.; 04/29/2022 at 04:00 p.m.; 04/29/2022 at 08:00 p.m.; 04/30/2022 at 11:00 a.m.; 04/30/2022 at 04:00 p.m.; and 04/30/2022 at 08:00 p.m Accucheck monitoring ACHS: the following results were not documented or not performed on the following dates/times: 04/22/2022 at 05:30 a.m.; 04/22/2022 at 04:00 p.m.; 04/26/2022 at 04:00 p.m.; 04/26/2022 at 08:00 p.m.; 04/27/2022 at 04:00 p.m.; 04/29/2022 at 11:00 a.m.; 04/29/2022 at 04:00 p.m.; 04/29/2022 at 08:00 p.m.; 04/30/2022 at 11:00 a.m.; and 04/30/2022 at 04:00 p.m. Review of the Medication Administration Record (MAR), dated April 2022 through May 05, 2022, revealed, in part, the following: [MEDICATION(S)] 14 units SubQ nightly at 08:00 p.m.: the following possible doses were documented illegibly on the following dates/times: 04/26/2022; 05/01/2022; and 05/02/2022. [MEDICATION(S)] 3 units SubQ three times daily with meals at 08:00 a.m., 11:00 a.m. and 05:00 p.m.: the following possible doses of were documented illegibly on the following dates/times: 04/27/2022 at 08:00 a.m.; 04/28/2022 at 05:00 p.m.; and 05/01/2022 at 12:00 p.m. Insulin - SubQ per SS ACHS: the following possible doses were documented illegibly on the following dates/times: 04/12/2022 at 12:00 a.m.; 04/13/2022 at 05:30 a.m.; 04/18/2022 at 04:00 p.m.; 04/19/2022 at 05:30 a.m.; 04/20/2022 at 05:30 a.m.; 04/21/2022 at 11:30 a.m.; 04/21/2022 at 04:00 p.m.; 04/22/2022 at 05:30 a.m.; 04/22/2022 at 04:00 p.m.; 04/23/2022 at 05:30 a.m.; 04/25/2022 at 05:30 a.m.; 04/25/2022 at 11:00 a.m.; 04/26/2022 at 11:00 a.m.; 04/28/2022 at 11:30 a.m.; 05/03/2022 at 08:00 p.m.; and 05/02/2022 at 08:00 p.m. Accucheck monitoring ACHS: the following results were documented illegibly on the following dates/times: 04/13/2022 at 05:30 a.m.; 04/18/2022 at 04:00 p.m.; 04/19/2022 at 05:30 a.m.; 04/20/2022 at 05:30 a.m.; 04/21/2022 at 04:00 p.m.; 04/23/2022 at 05:30 a.m.; 04/25/2022 at 05:30 a.m.; 04/25/2022 at 11:00 a.m.; 04/26/2022 at 11:00 a.m.; 04/30/2022 at 08:00 p.m.; 05/03/2022 at 08:00 p.m.; and 05/02/2022 at 08:00 p.m. On 04/27/2022 at 07:30 a.m., an observation of Resident # 9's 08:00 a.m. medication administration was performed with S7LPN. A total of 9 opportunities were observed with a total of 5 tablets given, no accucheck performed, no insulin doses administered and no topical powders applied for a total of 5 errors. In addition, upon leaving resident's room and returning to medication cart, S7LPN was observed to leave a blank space and not document the above missed opportunities as being held or refused on the resident's MAR. An interview was conducted on 04/27/2022 at 07:35 a.m. with Resident # 9, who confirmed he had not refused nor had he received his morning accucheck, his insulin doses or [MEDICATION(S)] prior to the observed medication pass. An interview was conducted on 04/27/2022 at 07:40 a.m. with S7LPN, who confirmed she had not performed the following orders for Resident # 9 during his Medication Pass: accucheck, insulin administration and topical powder application. She also confirmed the dose of [MEDICATION(S)] [MEDICATION(S)] did not have an accompanying physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/05/2022 at 11:40 a.m., an observation of Resident # 9's 11:30 a.m. medication administration was performed with S7LPN. A total of 3 opportunities were observed with the incorrect type of insulin administered per sliding scale and scheduled dose of 3 units for a total of 2 errors. An interview was conducted on 5/05/2022 at 11:40 a.m. with Resident # 9, who confirmed he was supposed to receive [MEDICATION(S)] instead of [MEDICATION(S)] R for the two doses of 11:30 a.m. insulin. An interview was conducted on 5/05/2022 at 11:45 a.m with S7LPN, who confirmed she administered [MEDICATION(S)] R during Resident # 9's 11:30 a.m. medication administration. An interview was conducted with S22NP and S23NP on 05/03/2022 at 01:55 p.m. S23NP stated upon admission the resident should have been receiving [MEDICATION(S)] 3u TID with meals and [MEDICATION(S)] sliding scale insulin ACHS and [MEDICATION(S)]. S22NP confirmed if a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . S22NP and S23NP both confirmed [MEDICATION(S)] and [MEDICATION(S)] R are not interchangeable because they work in different ways and confirmed Resident #9 should not have received [MEDICATION(S)] R. S22NP stated the incorrect insulin could be why they have not been able to control the resident's blood sugar levels. S22NP reviewed the April 2022 MAR with the surveyor and confirmed multiple insulins were not documented as being administered consistently and in his opinion would indicate why the resident's accucheck readings have been uncontrolled. On 05/05/2022 at 11:20 a.m., an interview was conducted with Resident # 9 who stated he was admitted to the facility following a hospitalization for high blood sugar levels and has had issues with controlling his glucose since he arrived to the facility. He stated he has been sent out to the hospital with elevated glucose levels. He confirmed the staff are not performing accuchecks and not providing insulin consistently or timely. He stated S7NP asked him to begin tracking and logging his own accucheck levels in order to get an accurate log to appropriately provide treatment. An interview was conducted with S2DON, S3ADON, and S19N present on 05/05/2022 at 12:45 p.m. S2DON reviewed Resident # 9's hospital discharge orders, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He also confirmed [MEDICATION(S)] and [MEDICATION(S)] are not interchangeable insulins. S3ADON stated that [MEDICATION(S)] R was the brand insulin the facility used for sliding scale standing orders. S3ADON stated she was responsible for transcribing new orders, including admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S3ADON stated she sometimes communicated via email with the facility's NP to question or clarify admit orders and would make changes to the admit order sheet and/or MAR based on that communication but would not write the new orders and/or order clarifications as a new verbal and/or telephone order to be reviewed and signed by the provider. S2DON confirmed any new orders, changes, and order clarifications should always be written as a verbal and/or telephone order then reviewed and signed off on by the ordering provider. S2DON also confirmed multiple occurrences of missing and/or illegible documentation of accuchecks and multple issues regarding missing and/or illegible documentation, inappropriately held and/or incorrect sliding scale dosing of insulins. S2DON confirmed he would expect Resident # 9's blood sugar to have been closely monitored with his insulin administered as ordered, especially following his hospital visit on 05/04/2022. S2DON confirmed a nurse could not make the decision to change a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S2DON reviewed Resident # 9's MARs dated 04/08/2022 through 05/05/2022 and confirmed the missing documentation of multiple doses of [MEDICATION(S)]. He confirmed if the resident did not receive his insulin as ordered, which could account for the continued fluctuations in blood glucose levels since the resident's admission. S2DON also confirmed multiple occurrences of missing and/or illegible documentation of accuchecks and multiple issues regarding doses not given, missing and/or illegible documentation and/or incorrect sliding scale dosing of insulins.

Based on observations, interviews, and record review, the facility failed to be administered in a manner that enables it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 8 (#1, #6, #8, #9, #12, R4, R5, R7) of 20 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, R1, R2, R3, R4, R5, R6, R7, and R8) sampled residents reviewed. The facility failed to have effective systems in place to: 1. Ensure the facility accurately and safely provided or obtained pharmaceutical services to ensure medications were acquired, available, and administered in a timely manner to meet the needs of the residents; 2. Ensure capillary blood glucose levels were obtained, Insulin was administered as prescribed, and medications were administered in accordance with professional standards and residents' person centered plans of care; and 3. Ensure agency staff nurses were oriented to facility polices regarding medication administration and following residents' person centered plans of care. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 beginning on 04/06/2022 at 08:00 p.m. when nursing staff failed to administer her second scheduled dose of [MEDICATION(S)] 24/26 mg, which was prescribed to treat a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 did not receive the second dose of [MEDICATION(S)] from 04/06/2022 through 04/22/2022 when she was transferred to the emergency room and diagnosed with a [CONDITION(S)] Exacerbation. Upon return to the facility, nursing staff continued to omit the second daily dose of [MEDICATION(S)]. This deficient practice resulted in an Immediate Jeopardy situation for Resident #9 beginning on 04/08/2022 upon admission to the facility when nursing staff failed to accurately transcribe admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in a total of 177 medication errors for Resident #9 from 04/08/2022 through 05/05/2022. In addition, Resident #9 did not consistently receive monitoring of blood glucose levels or doses of insulin for a total of 72 missed/inaccurate opportunities. These errors resulted in Resident #9 being transferred to the emergency roiagnom on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon return to the facility, the medication errors, inconsistent monitoring of blood glucose levels and inconsistent administration of hyperglycemic medications continued. S1ADM and S2DON were notified of the immediate jeopardy on 05/04/2022 at 07:00 p.m. The Verbal Plan for the Removal of Immediacy was approved on 05/04/2022 at 07:45 p.m. The Immediate Jeopardy was removed on 05/06/2022 at 03:25 p.m. when the provider presented an acceptable plan of removal. Through interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation of administration in a manner that uses resources effectively and efficiently to meet the needs of the resident by adhering to the facility's policies and systems related to pharmaceutical services, ongoing blood glucose monitoring, and documentation and tracking of narcotic medication counts. The DON and designee(s) completed a chart audit of all residents receiving medication for Pain Management, Diabetes Mellitus, and Cardiac Related Diagnoses. The Medication Administration Records (MAR) were reviewed against the physicians' orders to ensure transcription accuracy, medications timely acquired, documented appropriately, and administered as ordered. (Initiated 05/04/2022 at 08:00 p.m. Anticipated Completion Date 05/09/2022) - Any Negative Findings Will Be Corrected Immediately and DON/Designee Notified. The DON and Nursing Administrative staff completed a chart audit of residents with Diabetes Mellitus requiring blood glucose monitoring and insulin were reviewed to ensure accurate administration of insulin as ordered. (Initiated 05/04/2022 at 08:00 p.m. Anticipated Completion Date 05/09/2022) - Any Negative Findings Will Be Corrected Immediately and DON/Designee Notified. The DON and Nursing Administrative staff completed a review of narcotic medication counts against the MAR and medication card to ensure accurate documentation and procedures as outlined in the facility's Controlled Substance and Accountability Policy. (Initiated 05/04/2022 at 08:00 p.m. Anticipated Completion Date 05/09/2022) - Any Negative Findings Will Be Corrected Immediately and DON/Designee Notified. The Facility Medical Director or Nurse Practitioner will review all residents' current and active orders to determine accuracy. (Initiated 05/06/2022. Anticipated Completion Date 05/13/2022). Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. All applicable facility policies and procedures were reviewed by the administrative staff to ensure the systems established for pharmaceutical services, ongoing blood glucose monitoring, and documentation and tracking of narcotic medication counts are followed. (Completed 05/05/2022). Facility DON and ADON will receive education on monitoring and implementation of routine chart audits including Physicians Orders, Medication Administration Record, and Narcotic Logs by corporate Quality Assurance Nurse. Competency will be verified by exam and a pass rate of 90% or higher must be achieved. (Initiated 05/05/2022. Anticipated Completion Date 05/06/2022). The Administrative staff, DON or designee re-educated licensed nurses on facility policies regarding the following facility's policies and all nurses were educated prior to working their next shift: (Initiated 05/04/2022 at 08:00 p.m., All Licensed Nurses must receive education prior to shift). Medication Administration Policy Medication Error Policy Medication Monitoring Policy Unavailable Medications Policy Medication Reordering Policy Timely Administration of Insulin Policy Blood Glucose Monitoring Policy Controlled Substance Administration and Accountability Policy Facility Pharmacy Consultant, Corporate Quality Assurance Nurse, and Representatives from Pharmacy will be on hand to conduct a mandatory in person in-service with licensed nurses on Wednesday, May 11th at 02:00 p.m. A competency exam will be administered at the conclusion of this training and licensed nurses must prove knowledge by obtaining a pass rate of 90% or above on the exam. Any licensed nurse that does not attend mandatory in-service must review education materials provided during the training and complete exam with a pass rate of 90% or above before working any future shift. The DON or designee will monitor appropriate implementation by reviewing MARs, Narcotic Logs, and new orders during clinical startup meeting. (Initiated 05/05/2022 - Any Negative Findings Will Be Corrected Immediately) Will continue Louisiana Department of Health verifies monitoring until compliance. The DON will complete corrective action and one-to-one education on above listed topics with licensed nurse(s) identified as being deficient in their practice resulting in this citation. (Initiated 05/05/2022) The DON or designee will educate and supervise all current and new hire licensed nurses and agency nurses on the above policies, ensure adequate training, and are competent to provide appropriate care to residents according to their plan of care and facility's policies. Training will be included in orientation and annual competencies. Evidence of training will be maintained in the employee's personnel files. (Initiated 05/05/2022) The DON or designee will conduct weekly chart audits for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The audits will continue until compliance can be maintained for three consecutive months. (Initiated 05/05/2022) Will continue Louisiana Department of Health verifies monitoring until compliance. The DON and Nursing Administrative staff completed a chart audit of residents with Diabetes Mellitus requiring blood glucose monitoring and insulin were reviewed to ensure accurate administration of insulin as ordered. (Initiated 05/04/2022) Will continue Louisiana Department of Health verifies monitoring until compliance. The DON or designee will conduct a medication cross match weekly to identify the amount on hand is checked against the amount used daily from the documentation records of Controlled Substance Count and MAR. (Initiated 05/05/2022) Will continue Louisiana Department of Health verifies monitoring until compliance. The DON or designee will ensure standard nursing competencies are verified of all agency nurses by completing an orientation/training prior to shift and documenting on a checklist (Initiated 05/06/2022). Facility Administrator or Designee will monitor staffing levels in the facility by conducting labor huddles with Human Resources and Clinical Management to review time clock data as well as agency usage by reviewing agency shift reports to ensure adequate staffing levels are maintained (Initiated 05/06/2022). The DON and designees will complete match back of all medication carts and ensure accurate medications are on hand for all current orders. (Will Initiate Immediately Upon Completion of Physicians Order Review Being Conducted by Facility Medical Director/Nurse Practitioners). Findings: Review of the Pharmacy Service Agreement revealed the following, in part: Emergency Services Facility shall have available Emergency pharmaceutical services twent0fou hours per day, seven days per week in their Facility stock. Review of the Policy Titled, Medication Orders revealed the following, in part: Policy: This facility shall use uniform guidelines for the ordering of medication. 1. Medications should be administered only upon the signed order of a person lawfully authorized to prescribe. 2. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. (See Verbal Orders Policy) Documentation of Medication Orders: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] b. Clarify the order. c. Enter the order on the medication order and receipt record d. Call or fax the medication order to the provider pharmacy. e. Transcribe newly prescribed medications on the MAR or treatment record. f. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd and the date. g. Enter the new order on the MAR. h. Notify resident's sponsor/family of new medication order. Specific Procedures for Medication Orders: i. Handwritten Order Signed by the Physician - The charge nurse on duty at the time the order is received should note the order and enter it on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If necessary, the order should be clarified before the physician leaves the nursing station, whenever possible, j. Verbal Orders - The nurse should document an order by telephone or in person on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . k. Written Transfer Orders - (sent with a resident by a hospital or other health care facility) Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending, before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Example: Order verified by the phone with Dr. Smith/M. Jones, R.N. Review of the Policy Titled, Medication Administration revealed the following, in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign narcotic book. 20. Correct any discrepancies and report to nurse manager, Review of the Policy Titled, Controlled Substance Administration & Accountability revealed the following, in part: Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines: II. Discrepancy Resolution: a. Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered b. Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access. c. Additional reports may be available from the pharmacy. d. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy and possibly the State Licensure Board for Nursing Home Administrators. e. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. Review of the Policy Titled, Pain Management revealed the following, in part: Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: b. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body, or guarding a limb or other body parts) c. Fidgeting, increased or recurring restlessness d. Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw) i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming) Pain Assessment: 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information as applicable to the resident: a. History of pain and its treatment (including non-pharmacological, pharmacological, and alternative medicine (CAM) treatment and whether or not each treatment has been effective); c. Reviewing the resident's current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post [CONDITION(S)], venous and arterial ulcers, and [CONDITION(S)]). g. Impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood). h. Current prescribed pain medications, dosage and frequency. Review of the Policy Titled, Timely Administration of Insulin revealed the following, in part: Policy: It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition Policy Explanation and Compliance Guidelines: 1. All insulin will be administered in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. For current insulin orders, an adequate supply of insulin will be maintained for each resident. Insulin will be reordered as needed according to facility policy. 3. For new or emergency orders for insulin, the facility may use medications from the emergency kit. 4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order. Procedure: a. Review the insulin order: Resident name. ii. Medication name. iii. Medication dosage. iv. Time to be administered. v. Route of administration. b. Timely Administration of Insulin. b. Prepare insulin dose. Before administering insulin, perform two nurse verification of correct resident, dose calculations, and correct route of administration. c. Administer insulin at appropriate times. d. Document on the medication administration record the time and location of the insulin injection. Review of the Client Service Agreement and Contract for the agency staffing service revealed the following, in part: Agency is a software company that provides a technology platform for the healthcare facility and employed or independent contractor healthcare service provider (herein known as Professional Providers) to find one another with the purposes of engaging in a business-to-business arrangement whereby the tow may contract for services needed by the Client. 1.1 Agency is not a healthcare service company. The Client acknowledges that the agency is not a hiring entity or employer of Professional Providers. 1.2 Client acknowledges that Professional Providers are independent contractor operating as self-employers individuals who use the agency platforms and services to offer and provide healthcare services to Clients. Client acknowledges that the agency has no responsibility for, control over, or involvement in the scope, nature, quality, character, time or location of any work of services performed by Professional Providers between the Client and Professional Services 4.0 Agency Responsibilities 4.1 .3 Professional Providers are required to maintain and keep current the appropriate credentials, licenses, and or/certifications to provide the applicable healthcare services during a shift, or otherwise practice their respective disciplines, in accordance with any applicable Laws governing such healthcare services in the city and state in which the Professional Provider bids on, accepts, or fulfills any Shift. 5.0 Client Responsibilities Client understands and agrees that throughout the term the agency is not responsible for the performance or non-performance of any Professional Provider. The Client hereby further acknowledges and agrees that the Client is solely responsible for securing all permits, licenses, and or renewals required by any government authority for a Professional Provider to complete any and all requested, accepted, or approved shifts. 1. An interview was conducted with S2DON and S3ADON on 04/27/2022 at 01:30 p.m. S2DON confirmed the facility did not keep any standby narcotics in their Emergency Medication Kit. S3ADON further confirmed there were no narcotics in the facility that were not filled for a specific resident and those medications would have to be filled by the pharmacy. An interview was conducted with S3ADON on 05/03/2022 at 01:36 p.m., who stated she knew the facility had been having frequent issues for quite some time with getting medications filled in a timely manner by the pharmacy and she recalled having to place some medications on hold in the past for various residents because they did not have the medications on-hand. She further confirmed no one within the facility had ever identified or addressed potential ways to correct the problem. S3ADON then confirmed she was responsible for transcribing new orders, including admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was aware nurses were writing in orders on the MAR and faxing the MAR to the pharmacy, but the pharmacy should not fill the medication without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with S1ADM on 05/04/2022 at 03:00 p.m., who confirmed the facility did not provide any specific training or orientation for agency staff prior to or during their shift. He further stated he would expect them to ask a facility staff member for guidance on how to process a new medication order. He reviewed the staffing sheet and stated all staff were agency staff on the nightshift of 03/04/2022 and all shifts on 03/05/2022. He also confirmed given the staffing on 03/04/2022 and 03/05/2022, there were no facility staff nurses on-site for agency staff to utilize for guidance on submitting a new prescription for narcotic pain medication after hours. An interview was conducted with S2DON on 05/04/2022 at 03:20 p.m., who confirmed Resident # 12 continued to report uncontrolled pain but did not receive pain medication for more than 20 hours after the last dose in the Emergency Department because the medication was not available in the facility. He confirmed the medication was not available in the facility because the agency nurse assigned to the resident had not followed the proper procedure to obtain an after-hours prescription and there was no documentation to indicate anyone else from the facility ever followed up when the medication did not arrive within the expected timeframe. S2DON then confirmed he would have expected nurses to follow the after-hours procedure for filling medications and if the medication did not arrive, someone should have followed up with the pharmacy when they became aware the medication had not arrived. During an interview on 05/05/2022 at 11:05 a.m., S20RN confirmed she had noticed narcotics signed out on various Individual Patient's Narcotics Record but not signed on the corresponding section of the MAR. She confirmed she reported that information to the previous DON but was not aware of anything done about it. She confirmed there was supposed to be a narcotic count check at the end and start of each shift to verify the correct count and ensure the narcotic record matched the MAR. She then stated she rarely saw nurses do it and usually got push back whenever she insisted it be done with anyone she relieved or was relieved by during shift change. She stated she had voiced her concerns to administration some time ago regarding the push back but was not aware of anything done to change it. She also stated the charge nurses were supposed to perform and document a random narcotic check on each of the medication carts during their shift but she did not think many did and was not aware of anyone being held accountable for actually doing it. During an interview on 05/05/2022 at 2:30 p.m., S1ADM confirmed narcotics should be secured and locked in the medication cart for storage. He confirmed a narcotic count check should be performed at the end and start of each shift to verify the count and MAR matched and were accurate but was not sure if that had been monitored for being completed prior to him taking the position. He also confirmed if a narcotic were pulled from a resident's medication card and signed out on the Narcotic Count Sheet that meant the nurse had accepted possession of and assumed responsibility for that dose of the controlled substance. He confirmed after the narcotic count sheet was filled out, the nurse should then document the administration of the medication on that resident's MAR to indicate they had released the medication from their possession to the resident for it to be taken. He confirmed if the MAR documentation were not present, he would interpret that as diversion of a narcotic, along with a discrepancy in the narcotic count. A telephone interview was conducted with S9PC on 05/06/2022 at 11:23 a.m. She stated the facility was responsible for conducting their own investigation for missing narcotics. She stated the facility contacted her regarding one narcotic medication card missing, but they had not notified her of a pattern of missing narcotics. She stated it was left up to the facility if they notified authorities. An interview was conducted with S2DON on 05/06/2022 at 03:00 p.m., who confirmed if multiple cards were delivered as part of one narcotic prescription refill, he would expect the medication cards and the narcotic count sheets to have been marked 1 of __ cards to indicate the total number of cards sent for that prescription. He also confirmed there were only two narcotic count sheets created for Resident # R5 following the 03/23/2022 delivery of 120 doses of [MEDICATION(S)] 5/325mg (4 cards with 30 doses each card) which left 60 doses (2 cards with 30 pills each) unaccounted for and none of the narcotic count sheets were labeled __ of 4 cards to indicate the total doses received. He confirmed not having the cards labeled this way would make it difficult for an oncoming nurse to know if any cards of medications were missing. He confirmed he was not aware of any system that had been in place to ensure these processes were followed. He then confirmed if a narcotic was pulled from the medication card, it should have been documented on the Individual Narcotic Record and on the residents' MAR. He stated if the narcotic was not signed out on the residents' MAR there was no way of knowing where the medication went. He stated for new medication orders the nurse receiving the order was responsible for faxing it to pharmacy and updating the MAR. He stated there was no one responsible for checking the MAR behind the nurse. He stated if the medication was not signed, it was not given. He stated it was not acceptable for the nurse to say they gave it but did not or forgot to sign/document it on the MAR. He confirmed if the MAR documentation was not present, he would interpret that as diversion of a narcotic, along with a discrepancy in narcotic count created and would have to review policies with S1ADM to determine next steps. He then confirmed the dates administered on Resident # R5's MAR did not match the dates on the Narcotic Count Sheet and confirmed a total of 42 unaccounted for doses of Resident R5's [MEDICATION(S)] 5/325mg from the narcotic count sheets received on 01/18/2022, 03/23/2022 and 03/24/2022. 2. An interview was conducted with S2DON and S3ADON on 05/05/2022 at 12:45 p.m. S3ADON stated she sometimes communicated via email with the facility's NP to question or clarify admit orders and would make changes to the admit order sheet and/or MAR based on that communication but would not write the new orders/order clarifications as a new verbal/telephone order to be reviewed and signed by the provider. S2DON confirmed any new orders, changes, and order clarifications should always be written as a verbal/telephone order then reviewed and signed off on by the ordering provider. S2DON confirmed he would expect Resident # 9's blood sugar to have been closely monitored with his insulin administered as ordered. S2DON confirmed a nurse could not make the decision to change a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S2DON also confirmed Resident #9's recent visit to the emergency department due to uncontrolled blood glucose levels and confirmed if the resident had not had his blood glucose levels monitored closely and did not receive his insulin as ordered, it could account for the continued fluctuations in blood glucose levels since the resident's admission. 3. An interview was conducted with S3ADON on 05/03/2022 at 01:36 p.m., who stated agency staff were not trained or oriented on the procedure for having medications filled by the pharmacy. She stated there should be a sign in the Medication Room and it would be their responsibility to know it was there to read it for instructions on filling medications. An interview was conducted with S1ADM on 05/04/2022 at 10:35 a.m., who confirmed S4ADON was responsible for performing all training for facility nurses and CNAs, but prior to April 29 2022, no one at the facility was responsible for the agency staff. He confirmed they used agency staff to fill in staffing needs when needed but did not provide any specific training or orientation. He further stated a new agency staff member should receive a tour of the building at the beginning of their shift from any staff member that was available at the time. He confirmed no one at the facility was responsible for nor had anyone verified that abuse/neglect and dementia training was up to date for any agency staff or verified competency testing &/or skills check offs were successfully completed prior to being scheduled or allowed to work at the facility. He also confirmed the facility had not provided any of the education, testing and/or skills checks offs for agency staff while they were working within the facility. He stated if someone had a medical license or certification, he would expect him or her to meet any criteria and have the knowledge/skills necessary to work within the facility and thought the agency would ensure those things before allowing them to be scheduled. He confirmed he was the person responsible for scheduling agency staff and he only verified the following things: current license/certification, current background check and Covid-19 vaccination status. He then confirmed during the time period of 04/22/2022 through 04/29/2022, there were a total of 92 agency CNA shifts, 32 agency LPN shifts and 2 agency RN shifts scheduled and none of those had been verified for any training or competencies. An interview was conducted with S1ADM on 05/04/2022 at 03:00 p.m., who confirmed it was his expectation of agency staff that they should be able to work their scheduled shift and complete all necessary tasks without the need for any orientation or training as to the specific operations, p

Based on observations, interviews, and record reviews, the facility failed to ensure pain management was provided to residents who required such services, consistent with the comprehensive person-centered care plan and professional standards of practice for 3 (#6, #12 and R7) of 5 (#6, #9, #12, R5, and R7) residents reviewed for pain. This deficient practice resulted in actual harm for R7 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews with R7 and staff revealed R7 experienced severe, unrelieved pain on 04/30/2022 and 05/01/2022. R7 required an increase in her [MEDICATION(S)] dose on 05/04/2022. Findings: Review of the policy titled, Medication Orders revealed the following, in part: 1. Documentation of medication orders a. The order should be recorded on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] e. Transcribe newly prescribed medications on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the policy titled, Pain Management revealed the following, in part: Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: b. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body, or guarding a limb or other body parts) c. Fidgeting, increased or recurring restlessness d. Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw) i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming) Pain Assessment: 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information as applicable to the resident: a. History of pain and its treatment (including non-pharmacological, pharmacological, and alternative medicine (CAM) treatment and whether or not each treatment has been effective); c. Reviewing the resident's current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post [CONDITION(S)], venous and arterial ulcers, and [CONDITION(S)]). g. Impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood). h. Current prescribed pain medications, dosage and frequency. Review of the policy titled, Medication Orders revealed the following, in part: Policy: This facility shall use uniform guidelines for the ordering of medication. Documentation of medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] b. Clarify the order. c. Enter the order on the medication order and receipt record d. Call or fax the medication order to the provider pharmacy. e. Transcribe newly prescribed medications on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] f. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd and the date. g. Enter the new order on the MAR. h. Notify resident's sponsor/family of new medication order. Specific Procedures for medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] i. Handwritten order signed by the physician - The charge nurse on duty at the time the order is received should note the order and enter it on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If necessary, the order should be clarified before the physician leaves the nursing station, whenever possible, k. Written transfer orders - (sent with a resident by a hospital or other health care facility) Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending, before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Example: Order verified by the phone with Dr. Smith/M. Jones, R.N. Review of the Pharmacy Service Agreement revealed the following, in part: Emergency Services Facility shall have available emergency pharmaceutical services twenty four hours per day, seven days per week in their facility stock. Resident # R7 Review of the clinical record for R7 revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5 day MDS with an ARD of 02/16/2022 for R7 revealed the following, in part: Pain: been on scheduled pain med regimen - 1. Yes Review of the current Care Plan for R7 revealed the following, in part: Problem: I am at risk for pain. I have two abscesses on my back. Interventions: Administer medication as ordered. Review of the Telephone Order dated 04/25/2022 for R7 revealed the following: [MEDICATION(S)] Extended Release 15 milligrams one tablet by mouth every 12 hours [MEDICATION(S)] 5/325 milligrams one tablet by mouth every six hours as needed for pain Review of the April and May 2022 MAR for R7 revealed the following in part: [MEDICATION(S)] Sulfate Extended Release 15 milligrams one tablet by mouth every 12 hours with no signature on 05/01/2022 at 08:00 a.m. and 08:00 p.m. [MEDICATION(S)] 5/325 milligrams one tablet by mouth every six hours with no signatures on 04/30/2022, indicating R7 did not receive it. Review of the Individual Patient's Narcotics Record for R7 from 04/25/2022 to 05/04/2022 revealed the following, in part: Medication Name: [MEDICATION(S)] Sulfate Extended Release Dosage: 15 milligrams Remarks: take one tablet by mouth every twelve hours No entries on 04/30/2022 or 05/01/2022, indicating the medication was not prepared and R7 did not receive it. Review of the hospice visit note for R7 dated 04/28/2022 revealed the following, in part: Pain score (0-10): 7 Location of pain: back Frequency of pain: constant Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Increase [MEDICATION(S)] Sulfate to 30 milligram tablet, extended release two times daily by mouth. An observation was made of R7's available narcotics with S10LPN on 05/04/2022 at 11:20 a.m. R7 had [MEDICATION(S)] Sulfate and [MEDICATION(S)] available on the medication cart. An interview was conducted with S10LPN at that time. S10LPN verified R7 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . S10LPN verified R7's scheduled [MEDICATION(S)] Sulfate was not signed out as being removed from the narcotic drawer from 04/30/2022 through 05/01/2022 for all doses. S10LPN confirmed she was the nurse caring for R7. She stated R7 was cognitive and could answer questions appropriately. She stated R7 was on hospice services and experienced pain. An observation and interview was conducted with R7 on 05/04/2022 at 11:27 a.m. She was able to identify the current month, president, and the facility in which she resided. She confirmed she received hospice services and pain medication. She stated she was not receiving her pain medication as ordered and her pain was not controlled. During the interview, R7 was observed to have facial grimacing and continuously attempted to reposition herself in the bed and grab her back. R7 stated she had surgery to her back. She stated she had sutures in place and it was very painful. R7 continuously asked surveyor to assist her in getting pain medication during the interview. An interview was conducted with S2DON on 05/04/2022 at 11:35 a.m. He verified R7 did not receive her scheduled [MEDICATION(S)] for pain on 04/30/2022 or 05/01/2022. He confirmed R7 should have received [MEDICATION(S)] twice daily as ordered. An interview was conducted with S14CNA on 05/04/2022 at 12:58 p.m. She confirmed she was the CNA assigned to care for R7 from 06:00 a.m. to 02:00 p.m. She stated R7 had surgery to her back and she had sutures in place which caused R7 pain. She stated sometimes R7 hollered out in pain. An interview was conducted with R7's hospice nurse on 05/04/2022 at 01:33 p.m. She confirmed she was the hospice nurse for R7. She stated she assessed R7 on 04/28/2022 and her pain medication was not effective. She verified R7 should have received [MEDICATION(S)] Sulfate 15 milligrams by mouth every 12 hours and [MEDICATION(S)] 5/325 milligrams by mouth every 6 hours as needed for pain starting on 04/25/2022. She stated if R7 had not received her scheduled [MEDICATION(S)], she would expect her to be in severe pain. She confirmed R7's [MEDICATION(S)] Sulfate was increased to 30 milligrams by mouth every 12 hours on 05/04/2022 because R7's pain was not controlled and she did not know the facility was not administering the [MEDICATION(S)] as ordered. A telephone interview was conducted with S15CNA on 05/04/2022 at 02:00 p.m. She stated she worked from 06:00 p.m. to 06:00 a.m. on 04/30/2022 and 05/01/2022. She stated R7 was in pain on 04/30/2022 and 05/01/2022 all throughout her shifts. She stated R7 cried out and had tears from her eyes. She stated at times R7 would scream out saying her back was hurting. She stated on 05/01/2022, R7 asked for the nurse and she needed pain medication. She stated at the beginning of the night, R7 cried softly asking for pain medication and then throughout the night she started screaming in pain. She stated she reported the resident being in pain to S16LPN and S17LPN. An interview was conducted with S3ADON and S1DON on 05/04/2022 at 02:50 p.m. Both reviewed the MAR for R7 and confirmed R7 missed two doses of scheduled [MEDICATION(S)] on 04/30/2022 and 05/01/2022, which totaled four doses. They confirmed R7 should have received her pain medication as ordered. An interview was conducted with S16LPN on 05/04/2022 at 05:45 p.m. She confirmed she was assigned to care for R7 on 04/30/2022 and 05/01/2022 from 06:00 a.m. to 10:00 p.m. She stated R7 was in pain during both of her shifts and she did not administer her scheduled [MEDICATION(S)]. She verified the CNA reported R7 was in pain. She stated on 04/30/2022 and 05/01/2022, R7 complained of pain when she made medication rounds at least twice per shift. She stated at least one time on 04/30/2022 and 05/01/2022, R7 notified the CNA that she was in pain. She confirmed she did not give R7 any pain medication on 04/30/2022 and she only gave her one dose of [MEDICATION(S)] on 05/01/2022. An interview was conducted with R7 on 05/05/2022 at 10:41 a.m. She confirmed her [MEDICATION(S)] was increased to 30 milligrams every twelve hours on 05/04/2022. She stated she had a much better night last night. She stated her pain this morning was less than on 05/04/2022. Resident #6 Review of the Clinical Record revealed Resident #6 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)]/Acetaminophen 5/325 milligrams take 1 tablet by mouth 4 times daily as needed for pain. Review of the quarterly MDS with an ARD of 04/07/2022 revealed Resident #6 had a BIMS of 14, which indicated he was cognitively intact. Review of the current Care Plan for Resident #6 revealed the following, in part: Problem: I have chosen to receive hospice care. Intervention: Coordinate with the hospice team to assure I experience as little pain as possible. Problem: I am at risk for pain related to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Intervention: Administer medications as ordered. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] (Start date: 04/27/ ) [MEDICATION(S)] 5/325 milligrams one by mouth four times daily at 06:00 a.m., 12:00 p.m., 06:00 p.m., and 12:00 a.m. Signatures on the following dates and times indicating the medication was administered: 04/27/2022 at 06:00 p.m., 04/28/2022 at 12:00 p.m., (Start date: 04/28/2022) [MEDICATION(S)] Sulfate 30 milligrams every 12 hours Signatures on the following dates and times indicting the medication was administered: 04/28/2022 at 08:00 p.m., 04/29/2022 at 08:00 a.m., 05/03/2022 at 08:00 a.m. Review of the Facility Resident Sign In & Out Log for April 2022 revealed the following entry for Resident #6: Date: 04/29/2022, Time out: 04:30 p.m., Resident or person signing them out: daughter, and Where is resident going: home Review of the Individual Patient's Narcotic Record for Resident #6 revealed the following, in part: [MEDICATION(S)] Sulfate Extended Release 30 milligrams Amount received: 28 The following dates and times were documented as a tablet was removed: 04/28/2022 at 08:00 p.m., 04/29/2022 at 08:00 a.m., 05/03/2022 at 08:00 a.m. [MEDICATION(S)] 5/325 milligrams Amount received: 42 The following dates and times were documented as a tablet was removed: 04/27/2022 at 12:00 p.m., 04/27/2022 at 08:00 p.m., 04/28/2022 at 12:00 p.m., and 04/29/2022 at 12:00 p.m. An interview was conducted with S7LPN on 05/03/2022 at 11:45 a.m. She stated Resident #6 had chronic pain and always experienced pain. She stated his pain was normally to his back or generalized. She stated he admitted to the facility on hospice with pain medication orders. She stated Resident #6 came to her complaining of pain at least once per shift. She stated on 04/27/2022, Resident #6's [MEDICATION(S)] was changed from as needed to scheduled four times a day. She verified she transcribed the pain medication order from the Hospice nurse on 04/27/2022. She verified Resident #6 had not been receiving his pain medication scheduled since 04/27/2022 and he should have. An interview was conducted with S3ADON on 05/03/2022 at 11:55 a.m. She verified S7LPN changed Resident #6's [MEDICATION(S)]/Acetaminophen order on 04/27/2022 and the medication should have been being given scheduled since then and it had not. An interview was conducted with Resident #6 on 05/03/2022 at 11:57 a.m. He verified he was receiving hospice services. He stated he was in pain all the time from his waist down. He stated his pain had not been relieved with his current medication regimen. He confirmed he had not been receiving his [MEDICATION(S)] four times a day. An interview was conducted with the hospice nurse for Resident #6 on 05/03/2022 at 12:20 p.m. She verified she was Resident #6's hospice nurse. She verified she changed Resident #6's [MEDICATION(S)] 5 milligrams from as needed to four times daily scheduled on 04/27/2022. She stated when she made her visits at least weekly, Resident #6 was always in pain to his knees and feet. She stated on 04/27/2022, Resident #6's [MEDICATION(S)] Sulfate was increased to 30 milligrams twice daily. She stated Resident #6's pain was chronic. An interview was conducted with Resident #6's medical doctor on 05/03/2022 at 03:18 p.m. He stated he wanted Resident #6 to receive his [MEDICATION(S)] 5 milligram tablets scheduled four times daily to help control his pain. He stated per the hospice nurse's assessment, Resident #6's pain was not well-controlled so he changed the order. An interview was conducted with S3ADON and S2DON on 05/04/2022 at 02:50 p.m. Both confirmed Resident #6's [MEDICATION(S)] should have been given scheduled four times a day starting 04/27/2022, and it had not been. Resident #12 Review of the clinical record revealed Resident # 12 was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction, Muscle Weakness, Lack of Coordination, Cognitive Communication Deficit, Dysphagia, Dysarthria and [CONDITION(S)]. Review of the quarterly MDS with an ARD of 02/16/2022 revealed Resident # 12 had a BIMS of 14, which indicated she was cognitively intact. Review of the current Care Plan for Resident # 12 revealed the following, in part: Problem: I am at risk for pain. Intervention: Administer medication as ordered. Document effectiveness of pain medication. Review of the Incident Report, dated March 04, 2022, revealed, in part, the following: Date/Time: 03/04/2022 at 10:30 a.m. Unwitnessed Fall in Resident's Bathroom Describe Incident: Resident stated she fell while getting off toilet. Narrative of Incident: Resident at door calling for nurse, stating she fell while in restroom. Stated she was getting off toilet, missed her step, fell and hit her back and buttocks. Injuries: Yes; Fractured sacrum. Required acute transfer/admission? Yes, local emergency department. discharged back to facility same day. Review of Hospital Records for Resident #12 revealed the following, in part: Resident # 12 was seen in the local emergency roiagnom on [DATE] at 12:35 p.m. following an unwitnessed fall with complaints of headache, hip pain and left arm pain. Resident received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 12 was discharged back to the facility with a written prescription for [MEDICATION(S)] 10-325mg by mouth every 6 hours as needed for pain for up to 3 days starting 03/04/2022. Review of the Discharge Orders for Resident #12 revealed the following, in part: 03/04/2022 Written prescription sent with resident for [MEDICATION(S)] 10-325mg. Take 1 tablet by mouth every 6 hours as needed for pain for up to 3 days starting 03/04/2022. Review of the Nurses Notes for Resident # 12 revealed the following, in part: 03/04/2022 at 11:20 p.m. - Resident returned to the facility from hospital moaning and groaning in excruciating pain, 10/10. Discharge paperwork stated [MEDICATION(S)] last given at 01:51 p.m. Nurse practitioner contacted and ordered for resident to be sent back to hospital due to the facility not having the resident's pain medication available and pharmacy not being able to send until morning. 03/05/2022 at 01:20 a.m. - Resident returned to the facility from local emergency department after receiving pain medication. 03/05/2022 at 07:00 a.m. - Resident voiced pain concerns, nurse informed that her pain medication was on its way and that nurse will give Tylenol. Will continue to monitor. 05/05/2022 at 11:30 a.m. - Resident voiced pain at 5/10 from lower legs and sacrum. Will continue to monitor. No additional action/intervention indicated. 05/05/2022 at 03:30 p.m. - Resident voiced pain at 8/10. Nurse administered evening medications with Tylenol. Will continue to monitor. No additional action/intervention indicated. 05/05/2022 at 05:50 p.m. - Resident voiced pain, instructed to continue to relax. Will continue to monitor. No additional action/intervention indicated. Further review of Hospital Records for Resident #12 revealed the following, in part: Resident # 12 was again seen in the local emergency roiagnom on [DATE] at 12:47 a.m. with complaints of severe pain to buttocks. Physician notes indicated Seen here earlier today after a fall with sacral fracture. Did not have adequate pain medication at nursing home and cannot fill prescription that she was sent home with. Have ordered [MEDICATION(S)] by mouth. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 02/09/2022 Pain monitoring every shift via Pain Intensity Rating Scale; and 02/09/2022 Tylenol 650mg by mouth every 6 hours as needed for pain; 03/04/2022 [MEDICATION(S)] 10-325mg take 1 tablet by mouth every 6 hours as needed for pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Monitoring of pain level was not documented as ordered on the following dates and times: 03/04/2022 for the 02:00 p.m. - 10:00 p.m. shift; 03/04/2022 for the 10:00 p.m. - 06:00 a.m. shift; 03/05/2022 for the 06:00 a.m. - 02:00 p.m. shift; and 03/05/2022 for the 02:00 p.m. - 10:00 p.m. shift. Tylenol 650mg by mouth every 6 hours as needed for pain was administered on the following dates and times: 03/05/2022 with no date/time documented; and 03/05/2022 with no date/time documented. [MEDICATION(S)] 10-325mg by mouth every 6 hours as needed for pain was administered on the following date and time: 03/05/2022 at 08:48 p.m. A review of the Pharmacy Refill Log dated February 2022 through March 2022 for Resident # 12 revealed the following, in part: [MEDICATION(S)]/APAP 10-325mg Tablet, one tablet by mouth every 6 hours as needed for pain. Filled: 12 tablets on 03/05/2022. A telephone interview was conducted with S25PHARM on 04/27/2022 at 02:30 p.m., S25PHARM confirmed Resident # 12's prescription was received via fax on 03/05/2022 at 12:43 a.m. He then confirmed the on-call pharmacist was not called on the after-hours line to notify a prescription had been sent. He stated on 03/05/2022 in the morning, the faxed prescription for Resident # 12 was found but was not marked as a stat request. He confirmed Resident # 12's [MEDICATION(S)] 10-325mg was filled and picked up for delivery by the courier service on 03/05/2022 at 04:46 p.m. He confirmed had the prescription been marked stat, the prescription would have been filled and sent out for delivery within four hours or less. He confirmed any prescriptions sent after-hours or on weekends should always be followed up with a phone call. He stated all contracted facilities are aware of this policy regarding after hours prescriptions. An interview was conducted with S2DON and S3ADON on 04/27/2022 at 01:30 p.m. S2DON confirmed the facility does not keep any standby narcotics in their Emergency Medication Kit. S3ADON further confirmed they do not keep any narcotics in the facility that were not filled for a specific resident. An interview was conducted with S2DON on 05/04/2022 at 03:00 p.m., S2DON confirmed that he would have expected nurses to follow up with the pharmacy when they became aware the medication had not arrived to the facility. S2DON also confirmed Resident # 12 continued to report uncontrolled pain and was not able to receive her ordered pain medication until 03/05/2022 at 08:48 p.m., more than 20 hours after her last dose.

Based on observations, record reviews and interviews, the facility failed to ensure a resident received adequate supervision to prevent accident hazards by failing to supervise a cognitively impaired resident who exhibited wandering behaviors and eloped from the facility for 1 (#1) of 4 (#1, #2, #3, and #4) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation on 11/15/2020 when Resident #1, an [AGE] year-old cognitively impaired resident, eloped from a back exit door of the facility. At 2:45 a.m., according to the local enforcement officer, Resident #1 was found in the hospital parking lot 0.3 miles from the facility, after it was reported that a confused person was in the parking lot. The staff was unaware the resident left the facility until hospital staff at the local hospital identified Resident #1 by a previous hospitalization bracelet on his wrist. Hospital staff phoned the facility where they got no answer, and then physically went to the facility to notify them of Resident #1's location. A facility nurse then went to the local hospital parking lot to get the resident. The resident was returned to the facility at 6:00 a.m. The facility was notified of the Immediate Jeopardy on 12/11/2020 at 3:25 p.m. The Immediate Jeopardy was removed on 12/11/2020 at 4:35 p.m. when the provider presented an acceptable plan of removal. Through observation and interview, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. 1) Staff placed at back door 24/7 starting 12/10/2020. 24/7 staff stopped at 6AM 12/11/2020 after Maintenance assured there was no issues with mag lock as long as the lock was engaged and the code was not entered. Resident who eloped is also no longer in the facility as he discharged home. 2) Any other resident who is exit seeking and exhibiting wandering behaviors could be at risk of getting out the back door. No other residents were identified as of 12/11/2020. 3) In service with all staff to include noticing signs of exit seeking behaviors and reporting these behaviors to administration was conducted. Education and training to also include monitoring residents who are identified as elopement risk and identified in the elopement binder at the nurse's station. The training will be specific to each resident and the amount of supervision they need. In service also including ensuring there is nothing used to prop doors open, or in any way, allow doors to remain open. Elopement screens were done on all residents to ensure they are in the proper setting. Elopement screens started on 12/09/2020 and all will be completed by Monday, 12/14/2020. Monitoring tool of back door put in place to ensure proper working order. Separate monitoring tool put in place for all mag lock doors in the building. Camera System installed on 12/10/2020 to ensure staff compliance with door procedure. Administration staff in serviced to follow through on all reports of wandering and/or exit seeking behavior with proper assessment immediately. Nurses to round on elopement residents at a minimum Q2 hours per shift, or more if required after evaluation by the ID team. 4) Monitoring of mag lock doors will be conducted daily by the administrator or designee and kept on a QA tool for the next 4 weeks. Separate Monitoring tool of the back door to ensure proper working order. Weekly in services starting the week of 12/7/2020 will be done with staff for the next 4 weeks to include identifying residents with exit seeking behavior as well as making sure mag lock doors are working properly and not propped open. Competency checks will be done on staff to ensure staff understanding of reporting exit seeking residents and broken doors. These checks will be 3 times a week while making rounds on the hall by the administrator or designee starting the week of 12/7/2020. These checks will be kept on a QA tool. Nurses will have Q2 hours checks of elopement residents placed on their MAR. If checks are required more frequently those will also be placed on the nurses MAR. DON or designee will monitor the [DATE] times a week to ensure monitoring is taking place as required. DON or designee will also round on the hall 5 times per week to ensure nurses and all staff know who elopement risk residents are in the building. All results of this QA will be brought to the QA committee on 1/7/2021 to ensure substantial compliance. 5) Compliance date of 12/22/2020 with continue monitoring The deficient practice continued at a potential for more than minimal harm for the other 3 residents in the facility with wandering behaviors. Findings: Review of the Facility's policy Elopement and Wandering Residents revealed, in part: Policy: This facility ensures that residents who exhibit wandering behavior and/or risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered care plan for addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed. Elopement occurs when a resident leaves the premises of a safe area without authorization and/or necessary supervision to do so. Policy Explanation and Compliance Guidance: 1. The facility is equipped with door locks/alarms to help avoid elopements. 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risk, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. a. Residents will be assessed for risk of elopement and unsafe wandering throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to prevent accidents or elopements. e. Charge nurse and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Review of the facility's Safety and Supervision of Residents policy revealed the following, in part: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessment and observations to identify any specific accident hazards or risk for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision . System Approach to Safety: 2. Resident supervision is a core component of the systems approach to safety . 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when if there is a change in the resident's condition. Review of the clinical record revealed Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 11/09/2020 revealed an elopement risk score of 7. This indicated Resident #1 was a low risk for elopement. The evaluation included the resident's orientation was not determined/disoriented occasionally; ambulatory with one person assist; mobility was slightly limited; and the resident had not wandered or attempted to leave the facility. Review of the Resident Progress Notes revealed in part: 11/10/2020 at 9:39 a.m.: Resident admitted to the facility on [DATE]. Resident awake and responsive. Speech is clear with soft tone. Skill care for [DIAGNOSES REDACTED]. Resident refused medication this a.m. (morning) stated he has taken enough medicine. Nurse redirected and attempted to administer medication three different times. Resident refused all three times. Resident pacing around room without any assistive devices. Gait unsteady. Nurse instructed resident on using call light for assistance with ambulating for safety. 11/10/2020 at 1:22 p.m.: Resident required redirecting due to pacing, attempting to leave room several times. 11/10/2020 at 6:39 p.m.: Resident AAOx1, forgetfulness and confusion noted. Requires frequent redirecting. Speech clear and very low toned, usually has to repeat self to be understood. Ambulatory with slow, unsteady gait, although utilizes wheelchair. Has to be redirected to use w/c due to unsteady gait. 11/12/2020 at 1:44 p.m.: Resident requiring redirection and instructed to wear mask due to leaving room without assistive devices. Nurse explained to resident isolation policy and told him he was on isolation for 14 days. Resident did not comprehend and continued attempting to leave room until therapy went in room with resident. 11/13/2020 at 12:24 p.m.: Resident required redirection when attempting to leave room and ambulate without wheelchair. 11/15/2020 at 8:15 a.m.: Resident came and got a cup of water from my cart at 4:15 a.m. while I was doing my med pass. I (LPN) viewed the resident walking back to his room. At 5:30 a.m., a staff member from a local hospital came to alert us that one of the residents was sitting in the parking lot of the local hospital. I (LPN) got in my vehicle and went to the hospital and with help put the resident in the front seat and brought him back to the facility. I assessed resident upon arrival to his room. No injuries noted. I (LPN) asked resident how he got out of the building and he stated he left out of the back door. Resident is only oriented to self. He has to be reoriented to time and place. Resident's gait is steady. Notified DON at time of elopement. Notified MD. Notified Responsible Party who stated her dad is restless at night and tends to wander. She also stated she would be here Monday morning to talk with DON about the care plan. Resident has been moved to unit A. An interview/observation was conducted on 12/07/2020 at 7:43 a.m. with S1Owner. S1Owner entered the code in the back exit door keypad which opened the door. S1Owner then stood with the door propped open and confirmed there was no alarm sounding, S1Owner said, if there was an alarm, it would sound at the main nurse's station. At 7:44 a.m., S1Owner then called S9DW to come and stand in the back exit doorway, while he (S1Owner) went to the main nurse's station to verify if there was an alarm sounding in response to the exit door being propped open. S9DW stood against the opened door while S1Owner walked to the main nurse's station. At 7:46 a.m., S1Owner returned and verified there was no alarm sounding while the back door was propped open. An interview was conducted on 12/07/2020 at 7:45 a.m. with an anonymous staff member. The staff member said the door was propped open when there were deliveries and when the trash was being taken out. The staff member said the staff was not supposed to do it, but it happened all the time. An interview was conducted on 12/07/2020 at 8:40 a.m. with S3DON. She said Resident #1 was admitted to the facility on [DATE] and had no wandering behaviors. She said S6LPN reported to her on 11/13/2020 at approximately 2:00 p.m. that Resident #1 needed constant redirecting and was wandering out of his room. S3DON stated she responded to S6LPN by providing the definition of wandering and told S6LPN she would take care of it on Monday (11/16/2020) when S14SSD returned. She said S5LPN notified her on Sunday (11/15/2020) that Resident #1 had eloped out the facility's back exit door. An interview was conducted on 12/08/2020 at 1:55 p.m. with S6LPN. She said Resident #1 had been admitted on [DATE]. She said Resident #1 had a [DIAGNOSES REDACTED]. She said he had limited communication and would respond to questions by answering yes or no. She said he spoke very softly. She said he was able to slowly ambulate with an unsteady gait. She said he often left his room and had to be redirected multiple times a day. She said he needed increased supervision and the unit he initially resided was not the appropriate level of care for him. She said she notified S3DON on 11/13/2020 at 2:00 p.m. that Resident #1 needed increased supervision, redirection, and staff frequently had to escort him back to his room. She stated she notified the oncoming nurse on 11/13/2020 the resident had continuously attempted to exit his room and had to be redirected multiple times during her shift. She said when she was exiting the facility she observed the hall nurse escorting the resident by the hand and leading him back into his room. An interview was conducted on 12/09/2020 at 9:16 a.m. with S1Owner. He said S11MD made an adjustment to the exit door's magnetic closing device on 11/16/2020. He said after this adjustment the door would close and lock. He said the exit door was repaired again on 12/07/2020 due to the door slamming shut and bouncing open. An interview was conducted on 12/09/2020 at 10:16 a.m. with S7LPN. She said Resident #1 was confused and he was oriented to his name only. She said Resident #1 required constant redirection. She said his speech was in a low tone and he walked with an unsteady gait. She said he frequently said that he needed to leave. An interview was conducted on 12/09/2020 at 1:55 p.m. with S5LPN. She said on 11/15/2020 at 4:00 a.m., Resident #1 came to the medication cart and asked for a cup of water. She said the next thing she knew, a man came through the door and asked if there was a resident by the name of (Resident #1) missing from the facility. She replied, no, he's in his room. She said the man informed her the resident was sitting in front of the local hospital that was 0.3 miles away. She said she immediately left the facility, got in her car and drove to the hospital. She said when she arrived at the hospital, the resident was sitting in a wheelchair, outside the emergency room door. She said there were 4 or 5 hospital staff standing around him. She said she asked Resident #1 how he had gotten out of the facility and the resident said through the back door. She said she was not familiar with the resident or his mobility status. She said when she returned to the facility, she entered the facility through the back exit door. She said she pulled the back exit door open and entered the facility without putting the code in the keypad. She said the back exit door was not locked. An observation was made on 12/10/2020 at 8:21 a.m. of the facility's back exit door. Surveyor walked up to the door and pulled on the handle, the door opened easily and surveyor stepped into the doorway. A staff member was observed at the opposite end of the hall. Surveyor called out to the staff member. Staff member was asked to get S3DON. When S3DON arrived at the back exit door, she verified the back exit door was opened and was not secured. She said she was unaware the back exit door was left unsecured. A telephone interview was conducted on 12/10/2020 at 9:55 a.m. with S12RPD. She said her father (Resident #1) resided at the facility from 11/09/2020 - 11/26/2020. She said she had a conference call with administration prior to his admission to the facility and was informed that he would be placed on a secured locked unit because of his dementia diagnosis. She said during this call, she informed the staff that her father wandered and would leave the facility; therefore she wanted to make sure he was safe. She said the staff definitely knew he would leave out of the facility if left alone. She said she was shocked when the staff informed her on the morning of 11/15/2020 that her father had eloped out of the facility through the back exit door. She asked staff how could my father get out of the back door if the unit was locked. She said the administrator told her staff left the back door open when they went out to smoke. A telephone interview was conducted on 12/10/2020 at 4:32 p.m. with S8ERRN from hospital B. She said she was made aware of the incident on 11/15/2020 at approximately 4:00 a.m. She said on 11/15/2020 at approximately 4:00 a.m., she was notified of an elderly man wandering around the parking lot. She said at that time, she began assisting other hospital staff with locating the resident's home. She said the elderly man was dressed in a T-shirt, pajama pants, and slippers. She said it was approximately 50 degrees outside. She said the elderly man could not state his name. She said he had a hospital band on his wrist. She said another coworker called the assisted living facilities and nursing homes in the area. She said the facility where the resident resided had not answered the phone, so the coworker got in his vehicle and went to the facility. She said he knocked on the door and asked the staff at the nursing home if they were missing a resident and gave the resident's name (Resident #1). She said once Resident #1's nurse discovered Resident #1 was missing from the facility, she immediately took off running out of the facility, left the nursing home, and drove to hospital B in her private vehicle. She said Resident #1's nurse was in a panic. She said at the time the nurse arrived to retrieve Resident #1, the nurse did not know how he got out of the nursing home. A telephone interview was conducted on 12/11/2020 at 10:34 a.m. with S13LEO. He said he was working security detail at hospital B on 11/15/2020. He said on 11/15/2020 at approximately 2:45 a.m. an elderly man was observed by hospital staff to be wandering around the parking lot. He said the hospital staff was afraid to approach the man so they notified him (S13LEO). He said he approached the elderly man. He said the elderly man was incoherent, confused, and moving slowly with a limp. He was dressed in a short sleeve shirt, pajama pants, and slippers. He said he was wearing a hospital band on his wrist. He said he checked the wrist band and confirmed the man was not a current patient of the hospital. He said after some time and searching the medical facilities in the area, the man was found to be a resident from the nursing home facility behind hospital B. He said Resident #1 remained at hospital B for over an hour before the nurse from the facility came in a private vehicle to pick him up. An interview was conducted on 12/10/2020 at 2:00 p.m. with S3DON. She verified after she received a report from the S6LPN on the afternoon of 11/13/2020 regarding Resident #1's wandering behaviors, she had not implemented any new interventions to ensure Resident #1's safety.

Based on observations, interviews, and record reviews the facility failed to ensure appropriate alternatives were used prior to installing a bed or side rail for 11 (#1, #2, #5, #7, #8, #9, #10, #11, #12, #13 and #14) of 11 (#1, #2, #5, #7, #8, #9, #10, #11, #12, #13 and #14) residents reviewed for bed or side rails. The facility failed to: 1. Ensure the manufacturers' recommendations and specifications for the installation and maintenance of bed rails (#5, #7, #8, #9, #10, #11, and #12), 2. Ensure residents were assessed for appropriate indications for use of a side or bed rail related to a medical condition, risk for entrapment, and for the beds' dimensions as appropriate to the residents' sizes and weight (#1, #2, #5, #7, #8, #9, #10, #11, #12, #13 and #14) and, 3. Obtain informed consent prior to installation of the side or bedrail (#1, #2, #5, #7, #8, #9, #10, #11, #12, #13, and #14). This deficient practice resulted in an Immediate Jeopardy on 09/13/2019 at 4:30 a.m. when Resident #5 fell out of the left side of her bed due to the side rail not being secured to the bed frame and unsafe. Resident #5 was transferred to the emergency roiagnom on [DATE] at 5:46 a.m. where a CT scan revealed a moderate soft tissue contusion involving the left supraorbital frontal scalp and left anterior and anterolateral frontal scalp. There were multiple side rails in use on the residents' beds that were loose, not secure, and/or in need of maintenance. The Immediate Jeopardy was removed on 10/11/2019 at 4:05 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Plan of Removal included the following: 1.) A side rail assessment was completed on 10/10/2019 at 8:54 p.m. for Resident #5. As a result, side rails were removed for Resident #5. The side rail assessment indicated the resident would not benefit from the use of side rails at this time. The following was implemented to ensure the safety of the resident due to a previous fall on 09/13/2019: bed placed in lowest position, fall mat placed next to bed at resident's right side, and care plan updated. The resident's responsible party was notified of the removal of side rails, newly implemented interventions, and the updated care plan on 10/11/2019. 2.) Maintenance personnel began an audit on 10/09/2019 at 6:30 p.m. of all current beds with side rails to ensure the side rails were in working condition and functioning properly. One hundred percent of the audit was completed by 10/10/2019 at 9:00 p.m. All side rails were identified to be in working condition and functioning properly. 3.) Side rail assessments were done and reviewed by the interdisciplinary team on 10/10/2019 for residents using side rails to determine appropriate use and ensure the least restrictive measures were in place/attempted prior to implementing side rails. Completion date for all side rail assessments is 10/14/2019. Updating of physician orders, consents, and care plans to reflect those residents who met the criteria for use of side rails began on 10/10/2019 and will be completed by 10/14/2019. Staff Education: 1.) Current staff being re-educated by DON/ADON/Unit Managers or qualified designee regarding proper use of side rails: 2.) Education start date, 10/9/2019. Completion date on 10/14/2019. Education consisted of: Forms to be completed: side rail assessment, consent, orders/physician notification, care plan, and bed measurement process prior to placing side rails on any resident. 3.) Notification to the Administrator/Designee immediately when any staff observe a side rail is compromised, even after hours. If a side rails is compromised, and it is after hours, the staff are to transfer the resident to another available, safe, appropriate bed until such time that maintenance/designee can replace/fix the side rails identified as needing to be addressed. Staff Education Competency and Monitoring: 1.) Three interviews with direct care staff per week for four weeks will be conducted by DON/ADON/Unit Managers or qualified designee to ensure employees understand proper use and procedure for side rails. Documentation of the results of the interviews will be brought to QAPI committee for review. Ongoing Process started on 10/9/2019: 1.) Care staff will be educated on proper use and procedure for side rails by DON/ADON/Unit Managers or qualified designee and a follow up competency questionnaire will be completed during new hire orientation, annually thereafter, and as needed. 2.) Licensed nurses sign off on the medications administration record every shift for proper functioning of bed rails for those residents using bedrails. 3.) Side rail assessments to be completed upon admission/re-admission/significant change and quarterly for all residents in the facility during the timeframe the assessment is due. 4.) Maintenance/designee to complete a check of all side rails to ensure the rails are in good working order daily times thirty days, then twice weekly times one month then monthly as part of an ongoing facility process to ensure bed rails are functioning properly. The maintenance personnel are to replace and report immediately to the Administrator/designee any rails identified as not functioning properly. 5.) Administrator to conduct facility rounds with the Maintenance Director three times weekly for four weeks to visually inspect and ensure proper functioning of side rails. The Administrator will review the side rail inspection log weekly to ensure the log is current and follow up was completed as indicated. 6.) Director of Nursing/ADON/Unit Manager are to review the medical record and ensure the appropriate paperwork, processes had been obtained, and side rail use is appropriate prior to implementation. 7.) QAPI: Proper use and procedure for side rails to be added to facility's QAPI Program topics. The following will be reviewed monthly in QAPI Meeting: 8.) Nursing: Seven residents using side rails will be selected and the following will be reviewed on each resident: assessment completed, consent signed, physician order, care plan, bed system measurement test conducted, proper functioning validated by maintenance 9.) Maintenance: Administrator to conduct facility rounds with the Maintenance Director three times weekly for four weeks to visually inspect and ensure proper functioning of side rails. 10.) Administrator to review the side rail inspection log weekly to ensure the log is current and follow up was completed as indicated. The deficient practice remains at a level of potential harm for residents #1, #2, #5, #7, #8, #9, #10, #11, #12, #13, #14, and the other 66 residents identified by the facility as currently using side rails. Findings: Review of the Facility's Proper Use of Side Rails Policy revealed, in part: Purpose: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 2.) Side rails are only permissible if they are used to treat a resident's medical symptoms, or to assist with mobility and transfer of residents. 3.) An assessment will be made to determine the resident's symptoms, risk of entrapment, and the reason for using side rails. 4.) The use of side rails as an assistive device will be addressed in the resident care plan. 6.) Manufacturer instructions for the operation of side rails should be adhered to. 7.) The resident will be checked periodically for the safety relative to side rail use. 9.) When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. Review of the Weekly Bed Rails Inspection Log performed by maintenance staff revealed from 05/06/2019 to 10/07/2019 there were no entries indicating any bed rails in the facility required maintenance or repair. Resident #5 Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITIONS], Muscle Weakness, Lack of Coordination, Contracture of the Left Knee, Chronic Pain, and [MEDICAL CONDITION]. Review of the Quarterly MDS with an ARD of 08/27/2019 revealed Resident #5 had a BIMS of 8, which indicated moderate cognitive impairment. Resident #5's functional needs included total dependence with a two plus person physical assist for transfers and bed mobility. Review of Resident #5's August, September, and (MONTH) 2019 Physician order [REDACTED].¼ to ½ side rail enablers were ordered as needed for bed mobility and positioning. Review of Resident #5's Clinical record revealed no documentation of an informed consent for the use of side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #5's most recent Care Plan revealed no documentation that side rails were in use. Review of the August, September, and (MONTH) 2019 MARs for Resident #5 revealed in part: ¼ to ½ side rail enablers as needed for bed positioning and mobility. There was no documentation by staff indicating Resident #5 had a side rail in use during those months. Review of the Maintenance Log revealed, in part: Date: 09/13/2019 Room #: Bed A, confirmed to be Resident #'5s bed. Item being reported: 09/13/2019 Bed A's bed rail fell off the bed and was lose. Reported By: S25RNSUP Completed By: S11MS Review of the Nurse's Note revealed, in part: 09/13/2019 at 5:01 a.m., S26LPN reported Resident #5 had a fall and rolled out the left side of her bed due to the weakness of the side rail. Signed by S25RNSUP Review of the Safety Events-Fall Report for Resident #5 revealed, in part: Event Date: 09/13/2019 at 4:30 a.m. Description: Fall with injury Event Details: Unwitnessed, occurred in Resident #5's room Pain Observation: Pain was rated at a 5 out of 10 Body Observation: Bruising and Swelling Completed By: S7QALPN Review of Resident #5's CT scan of the head dated 09/13/2019 revealed: 1.) Moderate soft tissue contusion involving the left supraorbital frontal scalp and left anterior and anterolateral frontal scalp. Review of the emergency room Physicians History and Physical Dated 09/13/2019 at 6:15 p.m. revealed, in part: Comments: She has ecchymosis over the left frontal area as well as her left shoulder and left hand. Her lower extremity is contracted. Resident #5 again repeated that she was in her room alone, but she was too close to the edge of the bed and that caused her to fall. An interview was conducted with S11MS on 10/09/2019 at 9:06 a.m. He confirmed he had repaired the side rail on Bed A on 09/13/2019 after seeing the entry in the maintenance log stating the bed rail had fallen off the bed. He stated he had to change the entire bed rail for Bed A because the rail was hanging off the bed and barely attached by the brackets. An interview was conducted with S11MS on 10/09/2019 at 9:06 a.m. He confirmed he had repaired the side rail on Bed A on 09/13/2019 after seeing the entry in the maintenance log stating the bed rail had fallen off the bed. He stated he had to change the entire bed rail for Bed A because the rail was hanging off the bed and barely attached by the brackets. An interview was conducted with S23CNA on 10/09/2019 at 9:12 a.m. S23CNA confirmed she was familiar with Resident #5 and her care. She stated Resident #5 was unable to turn or move herself independently while in the bed. She stated Resident #5 required a bed rail to be up when she was in the bed. An interview was conducted with S15LPN on 10/09/2019 at 9:17 a.m. She stated Resident #5 was non-ambulatory and required maximum assistance of staff for transfers and bed mobility. She denied that the Resident would be able to intentionally release the side rail. She stated Resident #5 would not be able to fall out of the bed if the bed rail was up and functioning properly. An interview was attempted with S2DON on 10/09/2019 at 12:01 p.m. S2DON did not answer questions related to Resident #5 or the incident on 09/13/2019. An observation was made of Resident #5 on 10/10/2019 at 9:15 a.m. She was observed to be in her bed with ¼-side rail up on both the left and right side of the bed. She was lying on her left side with her back facing the outer side rail, and her back was observed to be touching the rail. Resident #5 appeared to be severely contracted, and unable to independently reposition herself or move while in the bed. An interview was attempted, but due to Resident #5's cognitive impairments, it was unsuccessful. An interview was conducted with S10MD on 10/10/2019 at 10:15 a.m. He stated he was contacted at 5:00 a.m. on 09/13/2019 due to Resident #5 falling out of bed. He reported he was told the bed rail had malfunctioned. Resident #1 Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS with an ARD of 07/09/2019 revealed Resident #1 had a BIMS of 7, which indicated severe cognitive impairment. Resident #1's functional needs included supervision and set up for bed mobility and transfers. Review of Resident #1's August, September, and (MONTH) 2019 Physician order [REDACTED].¼ to ½ side rail enablers were ordered as needed for bed mobility and positioning. Review of Resident #1's Clinical record revealed no documentation of an informed consent for the use of side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #1's most recent Care Plan revealed no documentation that side rails were in use. Review of the August, September, and (MONTH) 2019 MARs for Resident #1 revealed, in part: ¼ side rail enablers as needed for bed positioning and mobility. There was no documentation by staff indicating Resident #1 had a side rail in use during those months. An observation was made of Resident #1 on 10/08/2019 at 9:33 a.m. She was observed to be in her bed sleeping. The resident had ¼-side rail on the left side of the bed in use. Resident #2 Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION], Cognitive Communication Deficit, Unspecified [MEDICAL CONDITIONS], Age-Related Cognitive Decline, and Depression. A review of the Quarterly MDS with an ARD of 08/13/2019 revealed Resident #2 had a BIMS of 4, which indicated severe cognitive impairment. Resident #2's functional needs included extensive one-person physical assistance for bed mobility and total dependence with assistance of one person for transfers. Review of Resident #2's August, September, and (MONTH) 2019 Physician order [REDACTED].¼ to ½ side rail enablers were ordered as needed for bed mobility and positioning. Review of #2's Clinical record revealed no documentation of an informed consent for the use of side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #2's most recent Care Plan revealed no documentation that side rails were in use. Review of the August, September, and (MONTH) 2019 MARs for Resident #2 revealed, in part: No entry on the MARs for ¼ side rail enablers as needed for bed positioning and mobility. An interview was conducted with S4RVP on 10/11/2019 at 10:00 a.m. She confirmed Resident #2 had side rails on the bed prior to 10/09/2019. Resident #7: Resident #7's was a [AGE] year-old male admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS with an ARD of 07/03/2019 revealed Resident #7 had a BIMS of 12, which indicated he was moderately cognitively intact. Resident #7's functional needs included extensive one-person physical assistance for bed mobility and transfers. Review of Resident #7's August, September, and (MONTH) 2019 Physicians' Orders revealed on 05/24/2019 ¼ - ½ side rail as needed for bed mobility and positioning was ordered. Review of Resident #7's Clinical record revealed no documentation of an informed consent for the use of side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #7's most recent Care Plan revealed no documentation of side rails in use. Review of the August, September, and (MONTH) 2019 MARs for Resident #7 revealed, in part: No entry on the MARs for ¼ - ½ as needed for bed mobility and positioning. An observation was made of Resident #7 on 10/09/2019 at 1:18 p.m. He was lying supine in bed with the outer ¼-side rail up and in use. The outer side rail was assessed by the surveyor and noted to be loose, sliding back and forth several inches along the bed where it was attached. An observation was made on 10/09/2019 at 4:40 p.m. S1ADM was observed grabbing Resident #7's side rail on the bed causing it to move several inches along the rail to which it was not securely attached. When asked if the side rail was securely attached to the bed, S1ADM did not answer the question. An interview was conducted with Resident #7 on 10/10/2019 at 1:18 p.m. He stated he did not know if maintenance checked the side rails because he had never seen them do that. He stated the side rails had been in use since his admission. He stated he was unsure if he signed a consent for side rails. He denied discussing the removal of the side rails with the staff. Resident #8 Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses, which included Metabolic [MEDICAL CONDITION], Unspecified Dementia without Behavioral Disturbance, Muscle Weakness (Generalized), Lack of Coordination, and Cognitive Communication Deficit. Review of the Quarterly MDS with an ARD of 09/18/2019 revealed Resident #8 had a BIMS of 99, which indicated the resident was unable to complete the assessment. Resident #8's functional needs included extensive one-person physical assistance for bed mobility and transfers. Review of Resident #8's August, September, and (MONTH) 2019 Physician order [REDACTED].¼ to ½ side rail enablers were ordered as needed for bed mobility and positions. Review of Resident #8's Clinical record revealed no documentation of an informed consent for use of the side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #8's most recent Care Plan revealed no documentation that side rails were in use. Review of the August, September, and (MONTH) 2019 MARs for Resident #8 revealed, in part: No entry on the MARs for ¼ to ½-side rail enablers as needed for bed mobility and positioning. An observation was made of Resident #8 on 10/09/2019 at 2:49 p.m. Resident #8 was observed to be in bed and ½-side rail on each side of the bed was in use. An interview was conducted with S27CNA on 10/09/2019 at 2:52 p.m. She assessed the side rails on Resident #8's bed at this time and confirmed the right side rail was lose and maintenance needed to tighten it. Resident #9: Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses, which included Dementia, Cognitive Communication Deficit, and Non-displaced Intertrochanteric Fracture of Left Femur. Review of the Quarterly MDS with an ARD of 07/30/2019 revealed Resident #9 had a BIMs of 0, which indicated severe cognitive impairment. Resident #9's functional needs included total dependence of one person for bed mobility and transfers. No documentation of side rails in use on the MDS assessment. Review of Resident #9's August, September, and (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #9's Clinical record revealed no documentation of an informed consent for use of the side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #9's Care Plan revealed on 04/23/2019 an intervention of a ¼-side rail on the bed was implemented. Review of the August, September, and (MONTH) 2019 MARs for Resident #9 revealed, in part: no entry for a side rail use. Review of side rail manufacturers' information regarding proper installation and maintenance provided by administrative staff revealed no images in the information that resembled Resident #9's side rail. An interview was conducted with S2DON on 10/09/2019 at 4:22 p.m. S2DON stated Resident #9 had an assessment for risk of entrapment. She stated Resident #9 was assessed prior to the implementation of the side rail for risks, benefits, and alternatives. She stated Resident #9 was determined to benefit from side rail use. S2DON was unable to provide documentation of the above assessments for Resident #9. An observation was made on 10/09/2019 at 4:55 p.m. of S1ADM grabbing Resident #9's side rail on the bed causing it to move several inches in all directions. When asked if the side rail was securely attached to the bed, S1ADM did not answer the question. An interview was conducted with S5RCD on 10/10/19 at 12:10 p.m. She reviewed Resident #9's Physician Orders. She confirmed Resident #9 was admitted on [DATE] and did not have an order for [REDACTED]. Resident #10: Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus, [MEDICAL CONDITION] Disorder, Age-Related [MEDICAL CONDITION], and Obesity. Review of the Quarterly MDS with an ARD of 07/22/2019 revealed Resident #10 had a BIMS of 14, which indicated the resident was cognitively intact. Resident #14's functional needs included extensive one-person physical assistance for bed mobility and transfers. Review of Resident #10's August, September, and (MONTH) 2019 physician's orders [REDACTED].¼ to ½ side rail enablers were ordered as needed for bed mobility and positioning. Review of Resident #10's Clinical record revealed no documentation of an informed consent for the use of side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #10's most recent Care Plan revealed an intervention was added on 01/05/2013 for ¼ to ½ side rail enablers times two PRN for bed mobility and positioning. Review of the August, September, and (MONTH) 2019 MARs for Resident #10 revealed, in part: no entry for side rail in use. An observation was made on 10/09/2019 at 4:50 p.m. of S1ADM grabbing Resident #10's side rails on the bed, causing it to move several inches up and down, to which it was not securely attached. When asked if the side rail was securely attached to the bed, S1ADM did not answer. An interview was conducted with Resident #10 on 10/10/2019 at 1:59 p.m. She stated maintenance would come in and check the side rails every two to three months. She stated she did not have side rails when she was admitted to the facility, but when she moved to a new room the side rails were on the bed. She denied anyone speaking with her in regards to removing the side rails from her bed. Resident #11 Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses, which include Cerebral Infarction, Hypertension, Muscle Weakness, Abnormalities of Gait and Mobility, and Paranoid [MEDICAL CONDITION]. Review of the Quarterly MDS with an ARD of 08/20/2019 revealed Resident #11 had a BIMS of 8, which indicated moderate cognitive impairment. Resident #11's functional needs included a limited one-person physical assist for transfers and bed mobility. Review of Resident #11's August, September, and (MONTH) 2019 Physician order [REDACTED].¼ to ½ side rail enablers were ordered as needed for bed mobility and positioning. This order was discontinued on 10/09/2019, and ¼-side rail enabler as needed for bed mobility and positioning was ordered. Review of Resident #11's Clinical record revealed no documentation of an informed consent for use of the side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #11's Care Plan revealed no documentation that side rails were in use prior to 10/09/2019. Review of the August, September, and (MONTH) 2019 MARs for Resident #11 revealed, in part: ¼ side rail enablers as needed for bed positioning and mobility was initiated on 10/09/2019. An observation was made of Resident #11 in bed on 10/09/2019 at 8:55 a.m. The resident was observed to be in bed sleeping. The left side rail was observed to be pushed away from the bed, and lose enough for the resident to wedge a body part between the rail and mattress. An interview was conducted with S12AD and S22CNA on 10/09/2019 at 9:00 a.m. S12AD and S22CNA were asked to assess Resident #11's side rail. S22CNA grabbed the side rail and starting wiggling it back and forth. She confirmed the side rail was very loose and not attached properly to the bed. S22CNA was then observed to start and screw the side rail back on and tighten it to the bed. S22CNA reported Resident #11 could unscrew the side rail from the bed and that was what had caused it to be so lose. S12AD stated she had first observed Resident #11 unscrewing the bed rail from the bed over a month ago. S12AD then pointed out that Resident #11 was currently attempting to unscrew the side rail. She stated Resident #11 thought that was how to lower the side rail, and did not realize he was loosening it from the bed. S12AD and S22CNA confirmed the side rail on Resident #11's bed was too loose. Both also confirmed Resident #11 frequently unscrewed the side rail and he was not able to understand that he was loosening the side rail from the bed. S12AD and S22CNA denied informing anyone that Resident #11 was able to unscrew the bed rail. An observation was made on 10/09/2019 at 9:10 a.m. of S22CNA and S10MD entering Resident #11's room. The door was open and S10MD was observed to look at and shake the side rail on Resident #11's bed. There was no observation of S10MD replacing the side rail at that time. An observation was made on 10/10/2019 at 8:50 a.m. of Resident #11's bed and side rail. Resident #11 was in bed sleeping with the left side rail was up and in use. The side rail was observed to be the same side rail that Resident #11 was unscrewing from the bed on 10/09/2019 at 9:00 a.m. An interview was conducted on 10/10/2019 at 8:55 a.m. with S1ADM. S1ADM denied being aware Resident #11 was able to unscrew the side rail and loosen it. He confirmed there were alternative side rails that could have been placed on the bed. He stated staff should have made maintenance aware in order to put a side rail on the bed that did not screw onto the bed. He denied being aware S10MD had looked at the side rail yesterday and left it in place. Resident #12: Resident #12 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses, which included Anxiety Disorder, Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], Complications following Acute [MEDICAL CONDITION] Infarction, [MEDICAL CONDITION] Fibrillation, Acute Kidney Failure, Difficulty Walking, Cerebral Infarction, [MEDICAL CONDITION] Status, and Hypertension. Review of the Quarterly MDS with an ARD of 09/10/2019 revealed Resident #12 had a BIMS of 14, which indicated he was cognitively intact. Resident #14's functional needs included a limited one-person physical assistance for bed mobility and transfers. Review of Resident #12's August, September, and (MONTH) 2019 physician's orders [REDACTED].¼ to ½-side rail enablers were ordered as needed for bed mobility and positioning, and then discontinued on 10/09/2019. Review of Resident #12's Clinical record revealed no documentation of an informed consent for the use of side rails. Further record review revealed no documentation of an assessment for the use of the side rails, risk for entrapment or for the bed's dimensions as appropriate to the resident's size and weight prior to 10/09/2019. Review of Resident #12's most recent Care Plan revealed no documentation that side rails were in use. Review of the August, September, and (MONTH) 2019 MARs for Resident #12 revealed, in part: an entry dated 10/09/2019 was implemented for ¼-side rail enabler as needed for bed mobility and position. Review of side rail manufacturers' information regarding proper installation and maintenance provided by administrative staff revealed no images provided that resembled Resident #12's side rail. An interview was conducted with Resident #12 on 10/10/2019 at 12:45 p.m. He stated he did have side rails in use when he was admitted to the facility. He stated he did not remember anyone speaking to him about the side rails on his bed. He stated even though there were side rails on his bed he did not use them anymore and had not for quite a few months now. He stated he was unsure if he gave consent for the side rails. He denied that staff had spoken to him about removing the side rails from the bed. Resident #12 stated this week was the first time he had seen the maintenance crew come in his room to check the side rails since admission. During this interview, it was observed that Resident #12 had ¼-side rails times two on either side of the bed in the down position. Resident #13 Resident #13 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses, which include [NAME]

Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 11 (#1, #2, #5, #7, #8, #9, #10, #11, #12, #13 and #14) of 11 (#1, #2, #5, #7, #8, #9, #10, #11, #12, #13 and #14) residents reviewed for bed or side rails. The facility failed to ensure there was an effective system in place for the use of bed or side rails including appropriate assessments and indications for use, informed consents and the proper installation and maintenance of the bed or side rails per the manufacturer's recommendations and specifications. There were 77 residents identified in the facility that used side rails. This deficient practice resulted in an Immediate Jeopardy on 09/13/2019 at 4:30 a.m. when Resident #5 fell out of the left side of her bed due to the side rail not being secured to the bed frame and unsafe. Resident #5 was transferred to the emergency roiagnom on [DATE] at 5:46 a.m. where a CT scan revealed a moderate soft tissue contusion involving the left supraorbital frontal scalp and left anterior and anterolateral frontal scalp. There were multiple side rails in use on the residents' beds that were loose, not secure, and/or in need of maintenance. The Immediate Jeopardy was removed on 10/11/2019 at 4:05 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Plan of Removal included the following: 1.) A side rail assessment was completed on 10/10/2019 at 8:54 p.m. for Resident #5. As a result, side rails were removed for Resident #5. The side rail assessment indicated the resident would not benefit from the use of side rails at this time. The following was implemented to ensure the safety of the resident due to a previous fall on 09/13/2019: bed placed in lowest position, fall mat placed next to bed at resident's right side, and care plan updated. The resident's responsible party was notified of the removal of side rails, newly implemented interventions, and the updated care plan on 10/11/2019. 2.) Maintenance personnel began an audit on 10/09/2019 at 6:30 p.m. of all current beds with side rails to ensure the side rails were in working condition and functioning properly. One hundred percent of the audit was completed by 10/10/2019 at 9:00 p.m. All side rails were identified to be in working condition and functioning properly. 3.) Side rail assessments were done and reviewed by the interdisciplinary team on 10/10/2019 for residents using side rails to determine appropriate use and ensure the least restrictive measures were in place/attempted prior to implementing side rails. Completion date for all side rail assessments is 10/14/2019. Updating of physician orders, consents, and care plans to reflect those residents who met the criteria for use of side rails began on 10/10/2019 and will be completed by 10/14/2019. Staff Education: 1.) Current staff being re-educated by DON/ADON/Unit Managers or qualified designee regarding proper use of side rails: 2.) Education start date, 10/9/2019. Completion date on 10/14/2019. Education consisted of: Forms to be completed: side rail assessment, consent, orders/physician notification, care plan, and bed measurement process prior to placing side rails on any resident. 3.) Notification to the Administrator/Designee immediately when any staff observe a side rail is compromised, even after hours. If a side rails is compromised, and it is after hours, the staff are to transfer the resident to another available, safe, appropriate bed until such time that maintenance/designee can replace/fix the side rails identified as needing to be addressed. Staff Education Competency and Monitoring: 1.) Three interviews with direct care staff per week for four weeks will be conducted by DON/ADON/Unit Managers or qualified designee to ensure employees understand proper use and procedure for side rails. Documentation of the results of the interviews will be brought to QAPI committee for review. Ongoing Process started on 10/9/2019: 1.) Care staff will be educated on proper use and procedure for side rails by DON/ADON/Unit Managers or qualified designee and a follow up competency questionnaire will be completed during new hire orientation, annually thereafter, and as needed. 2.) Licensed nurses sign off on the medications administration record every shift for proper functioning of bed rails for those residents using bedrails. 3.) Side rail assessments to be completed upon admission/re-admission/significant change and quarterly for all residents in the facility during the timeframe the assessment is due. 4.) Maintenance/designee to complete a check of all side rails to ensure the rails are in good working order daily times thirty days, then twice weekly times one month then monthly as part of an ongoing facility process to ensure bed rails are functioning properly. The maintenance personnel are to replace and report immediately to the Administrator/designee any rails identified as not functioning properly. 5.) Administrator to conduct facility rounds with the Maintenance Director three times weekly for four weeks to visually inspect and ensure proper functioning of side rails. The Administrator will review the side rail inspection log weekly to ensure the log is current and follow up was completed as indicated. 6.) Director of Nursing/ADON/Unit Manager are to review the medical record and ensure the appropriate paperwork, processes had been obtained, and side rail use is appropriate prior to implementation. 7.) QAPI: Proper use and procedure for side rails to be added to facility's QAPI Program topics. The following will be reviewed monthly in QAPI Meeting: 8.) Nursing: Seven residents using side rails will be selected and the following will be reviewed on each resident: assessment completed, consent signed, physician order, care plan, bed system measurement test conducted, proper functioning validated by maintenance 9.) Maintenance: Administrator to conduct facility rounds with the Maintenance Director three times weekly for four weeks to visually inspect and ensure proper functioning of side rails. 10.) Administrator to review the side rail inspection log weekly to ensure the log is current and follow up was completed as indicated. The deficient practice remains at a level of potential harm for residents #1, #2, #5, #7, #8, #9, #10, #11, #12, #13, #14, and the other 66 residents identified by the facility as currently using side rails. Findings: Cross Reference F700 Review of the Job Description and Performance Standards for the facility Administrator revealed, in part: Purpose of the Position: Establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with the federal, state, and local requirements. Delegation of Authority: Authority is delegated to the individual in this position to: Develop, maintain, and implement operational policies and procedures to meet resident's needs in requirements with federal, state, and local requirements; and Develop a monitoring system to assure compliance with federal, states, and local requirements. Review of the Job Description and Performance Standards for the facility Director of Nursing Services revealed, in part: Purpose of the Position: Provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. Delegation of Authority: Authority is delegated to the individual in this position to: Set resident care standards in accordance with acceptable standards of care to provide high quality care to residents; Develop and implement policies and procedures for nursing care of residents; Supervise and manage all aspects of the nursing department; and Assess, direct, and supervise residents' care needs Review of the Facility's Proper Use of Side Rails Policy revealed, in part: Purpose: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 2.) Side rails are only permissible if they are used to treat a resident's medical symptoms, or to assist with mobility and transfer of residents. 3.) An assessment will be made to determine the resident's symptoms, risk of entrapment, and the reason for using side rails. 4.) The use of side rails as an assistive device will be addressed in the resident care plan. 6.) Manufacturer instructions for the operation of side rails should be adhered to. 7.) The resident will be checked periodically for the safety relative to side rail use. 9.) When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. Review of the Weekly Bed Rails Inspection Log performed by maintenance staff revealed from 05/06/2019 to 10/07/2019 there were no entries indicating any bed rails in the facility required maintenance or repair. An interview was attempted with S2DON on 10/09/2019 at 12:01 p.m. S2DON did not answer questions related to Resident #5 or the incident on 09/13/2019. She also did not answer questions in regards to the facility's processes on side rail use. An interview was conducted with S1ADM on 10/10/2019 at 9:20 a.m. He stated he was trying to get the manufacturer's recommendations for the side rails in the facility, but could not find them. He stated he would have to talk to maintenance to see how the manufacturers recommendations were being followed if the information was not available. He stated the risk for entrapment and bed dimensions had not been assessed or documented until yesterday, 10/09/2019 for the 77 residents identified as having side rails. An interview was conducted with S10MD 10/10/2019 at 10:15 a.m. He stated the maintenance staff checked all side rails in the building weekly and documented the results on a weekly log. He reviewed the weekly logs from (MONTH) 2019 to present and stated there was no documentation that a side rail had been lose or required repair during that time. S10MD then stated his staff would fix the side rails as needed, but did not always document the repair on the log. He stated all the maintenance staff was trained on how to install, maintain, and remove the side rails in the building; however, S10MD was unable to provide documentation of the trainings. He stated there were some beds in the facility that had come from a DME company and he was unsure of what type of side rail was on those beds. He stated he had been doing this a long time and he knew from memory the maintenance that the different types of side rails required. He confirmed he did not have the manufacturer's recommendations for all the different types of side rails in the facility. An interview was conducted with S5RCD on 10/10/2019 at 2:58 p.m. She denied being aware of how staff were monitoring the side rails for safety. An interview was conducted with S5RCD and S4RVP on 10/11/2019 at 10:00 a.m. Both confirmed the facility was unable to present the manufacturers recommendation for all types of bed rails used in the facility and unable to provide a list of the different types of side rails in use. Both confirmed alternative interventions had not been attempted prior to bed rail use for all 77 residents identified as having side rails. S4RVP confirmed the bed rail assessments and dimensions had not been completed prior to 10/09/2019 for all residents in the building. S5RCD confirmed side rail consents had not been completed for any of the 77 residents identified as having side rails in the facility. An interview was conducted with S3VPO on 10/11/2019 at 4:30 p.m. She confirmed consents had not been completed, alternative methods had not been implemented prior to bed rail use, and manufacturer's guidelines had not been followed. She further confirmed risk of entrapment assessments and bed rail dimensions in accordance with the resident's height and weight had not been completed prior to 10/09/2019.

Based on interview and record review, the facility failed to provide each resident with sufficient fluid intake to maintain proper hydration and health for 1 (#1) of 5 (#1, #2, #3, #4, #5) residents by failing to: a) increase fluids for a resident (#1) identified as high risk for dehydration after the resident developed an infection and a prolonged elevated temperature and b) consistently monitor the resident's Intake and Output. This failed practice resulted in a harm to the resident on 9/4/14 when he developed Severe Dehydration, Lactic Acidosis and a blood Glucose of greater than 1000. Findings: A review of the facility's Policy & Procedure for Blood Pressure Monitoring revealed, in part, the following: [MEDICAL CONDITION] (low blood pressure): less than 100/60. A review of the facility's Policy & Procedure for Respirations Monitoring revealed, in part, the following: The normal respiration rate for an adult is from 12-18 times per minute. A review of the facility's Policy & Procedure for Hydration revealed, in part, the following: The physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example, those with prolonged fever, or who are taking diuretics ... . A review of the clinical record for Resident #1 revealed the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set revealed the resident required total assistance with all activities of daily living. A review of the Hydration Risk assessment dated [DATE] revealed the resident was identified to be at high risk for dehydration. A review of Potter & Perry. Fundamentals of Nursing Concepts Process & Practice, Third Edition, Chapter 39, p.1295 revealed, in part, the following: "Measuring and recording all liquid intake and output during a 24-hour period helps complete the assessment data base for fluid, electrolyte, and acid-base balances. Intake includes all liquids taken orally, by feeding tube and parentally. ... Liquid out-put includes urine, diarrhea ... Generally, I & O are routinely measured for clients after surgery and clients whose conditions are unstable, who have fever, whose fluids are restricted, or who are receiving diuretic or IV therapy. A review of Resident #1's Nursing Admission Evaluation dated 7/25/14 revealed the following: Temp. 98.7; P: 82, BP: 139/84, RR: 20 A review of Resident #1's Admission Lab results dated 7/27/14 revealed the following: Chemistry Panel: Na - 131 L -- Reference Range: 136-145 K - 5.0 -- Reference Range: 3.5-5.1 Cl - 97 L -- Reference Range: 100-109 Glucose - 210 H -- Reference Range: 70-100 BUN Level - 28 H -- Reference Range: 5-25 Creatinine - 0.84 -- Reference Range: 0.57-1.25 A review of the Care Plan for Resident #1 revealed, in part, the following: a)Problem Onset: 7/25/14 Resident is at risk for dehydration related to Nothing By Mouth (NPO) status. Nurse monitors for signs/symptoms of dehydration. None at present. Goal & Target Date: 10/25/14 Approaches: Staff will monitor for signs and symptoms of dehydration and Urinary Tract Infection Staff will keep fluids within reach of resident Staff will monitor resident for changes in mental or physical status and notify physician b)Problem Onset: 7/25/14 Potential for hyperglycemic episodes secondary to Diabetes. Goal & Target Date: 10/25/14 Approaches: Accu-checks as ordered by physician A review of the August 2014 and September 2014 Physician order [REDACTED]. Indwelling Foley urinary catheter Peg Tube with Glucerna 1.2 at 70ml per hour, to infuse for 22 hours a day Water flush 200cc four times daily Flush Peg Tube with 30cc water before and after medications [MEDICATION NAME] 1 Gram Intravenous every 12 hours Sodium Chloride 1gram, give 2 tablets twice day [MEDICATION NAME] 10mg every other day via peg tube Humalog Insulin - sliding scale Accucheck every 6 hours (6:00am, 12:00pm, 6:00pm, 12:00am) A review of the Registered Dietitian's Enteral Nutrition Progress Notes dated 8/6/14 revealed the following: Medications: Humalog (Insulin), [MEDICATION NAME] (Diuretic) Enteral Feeding Provides 2200cc free water (total), greater than 100% of estimated fluid needs. A review of the Nurse's Notes for Resident #1 revealed that on 8/24/14, 4:00pm, the resident had a positive sacral wound culture for infection. On 8/25/14, 3:00pm, the resident was ordered [MEDICATION NAME] (antibiotic) 1Gram, Intravenous (IV), every 12 hours for 10 days. On 8/26/14, 4:10pm an intravenous access site was obtained. On 9/1/14, 3:30pm, the intravenous access site became dislodged. On 9/2/14, 10:50am a new intravenous access was obtained, antibiotic therapy was resumed. A further review of the Nurses' Notes for Resident #1 revealed the following: 9/3/14, 12:00am - Temp: 99.2 9/3/14, 8:00pm - Temp: 100.4, Tylenol 650mg given 9/4/14, 10:00am - Temp: 101.4, Tylenol 650mg given 9/4/14, 1:10pm - Temp: 99.2 9/4/14, 4:00pm - P:84, RR:20, BP:122/64, Temp: 101.3, Tylenol 650mg given 9/4/14, 8:30pm - P:101, RR:30, BP: 80/63, Temp: 101.3 9/4/14, 11:45pm - P:100, RR: 45, BP:70/37, Temp: 101.0 A review of the Diabetic Monitoring Record (Accu-check with Sliding Scale (SS) Insulin Administration) for Resident #1 revealed, in part, the following: 9/4/14: 12:00am - accu-check: 445 - SS Insulin: 12 units (u) administered 6:00am - no documented accu-check done 12:00pm - accu-check: 422 - SS Insulin: 12u administered 6:00pm - no documented accu-check done A review of the September 2014 Activity of Daily Living (ADL) Flowsheet for Resident #1 revealed, in part, the following: URINE per shift: Day shift: No documentation of resident's urinary output Evening shift: 9/1/14 - 800cc 9/2/14 - 400cc 9/3/14 - 900cc 9/4/14 - 150cc Night shift: 9/1/14 - no documentation of urinary output 9/2/14 - 600cc 9/3/14 - no documentation of urinary output Further review of the September 2014 ADL Flowsheet for Resident #1 revealed the following: BOWEL MOVEMENTS per shift (L = Loose, S = Soft): 9/1/14 - Day: 2/S; Evening: 2/L; Night: 1/S 9/2/14 - Day: 2/S; Evening: scratched out/S; Night: 2 9/3/14 - Day: 2/S; Evening: 1/L; Night: Blank 9/4/14 - Day: Blank; Evening: 1/L; Night: "Out" A review of Resident #1's Laboratory Reports revealed, in part, the following: 9/4/14, collected at 11:14pm Chemistry Panel: Na - 160 High (H) -- Reference Range: 136-145 K - 5.3 H -- Reference Range: 3.5-5.1 Cl - 122 H -- Reference Range: 100-109 Glucose - 1092 Critical (C) -- Reference Range: 70-100 BUN Level - 135 C -- Reference Range: 5-25 Creatinine - 3.42 H -- Reference Range: 0.57-1.25 Urinalysis: Color: Orange -- Reference Range: Yellow Clarity: Cloudy - Reference Range: Clear Leukocyte Esterase: Large - Reference Range: Negative WBC - 20-50 - Reference Range: 0-5 RBC - 5-10 - Reference Range: 0-5 A review of Resident #1's Physician order [REDACTED]. A review of the hospital record for Resident #1 revealed the following: Resident arrived at emergency department by ambulance on 9/5/14 at 00:48. Triage Assessment - Presenting problem description: [MEDICAL CONDITION], lethargy and abnormal labs. Emergency department assessment: Blood Glucose greater than 600, BP: 54/38, Oxygen at 6 Liters per minute. Impression and Plan - Admit work up revealed Severe Dehydration and Lactic Acidosis. Hospital Physician Consult dated 9/7/14: Neurologic: Resident is nonverbal and does not move any extremities. Assessment and Plan: -Severe [MEDICAL CONDITION] secondary to exacerbation from salt tablets in the setting of free water deficiency along with underlying diuresis. -Shock, [MEDICAL CONDITION]. The patient has a grossly abnormal urinalysis with greater than 100 white and red cells. -[MEDICAL CONDITIONS]. The patient does have stools positive for[DIAGNOSES REDACTED]icile that were present on admission. -Acute kidney injury. The patient presented with severe elevation of BUN and creatinine. -Severe [MEDICAL CONDITION] On 9/9/14 at 1:41pm an interview was conducted with S2LPN for Resident #1. She stated that he was non-verbal, had a foley urinary catheter, a [MEDICAL CONDITION], not on a ventilator and had a PEG tube used for continuous feeding and medications. She stated that he was total care. She stated that the resident was a Diabetic, had an order for [REDACTED]. She stated that in August the resident was treated with antibiotics for a urinary tract infection [MEDICAL CONDITION]. She stated that on 8/25/14, the resident was started on IV antibiotics for a wound infection. She stated that he went to the hospital on [DATE] at about 11:45pm. She stated that she worked with Resident #1 during the day shift on 9/4/14 and his urine was yellow and clear. She stated that the CNAs empty the urinary catheter bags and write the output on the resident's ADL Flowsheet. She stated that after the resident developed the wound infection, his blood Glucose varied. On 9/9/14 at 5:25pm an interview was conducted with S8LPN. She stated that the only time we do I & O is when we have a physician's orders [REDACTED]. She stated that if there are any problems like it wasn't given, then they would circle it. She stated that they nurses don't write the amount of fluids received in numbers. On 9/9/14 at 5:32pm an interview was conducted with S3LPN. She showed surveyor a MAR and stated that it documents the brand of feeding, flush with ccs of water and what the the amount of ml/hr the tube feedings are infusing at. She stated that there was no space on the MAR for each nurse to document the actual amount of fluid received by a resident. She stated that there is no documentation of the exact amount of intake in numbers and we don't document it in the nurses notes. She stated that if you were going to calculate I & O for a resident, you would have to break it down in numerical amounts. She stated that if you need to know how much you are giving and compare with what is coming out of the patient, then an I & O would be good to do. On 9/10/14 at 11:19am an interview was conducted with the RD for the facility. She stated Resident #1 was admitted on [DATE] with PEG tube feeding of Glucerna 1.2 at 70cc/hr, 22 hours a day. She stated that his PEG tube formula had not been changed since he was admitted to the facility. She stated that she knew that he had a wound to his sacrum. She stated that she wasn't consulted about a UTI for him. She stated that for him his tube feedings gave him 1,848 calories with 92 gm of protein, and it provided 2,200 ml per day of fluids that was total to include all flushes, formula and added water. She stated that she had calculated his caloric requirements to be 1700-1900 on admit. She stated that his wound was included in her calculations, but she did not know that he had been treated for [REDACTED]. She stated that had she known about the infections, she would have evaluated to see if the resident required increased fluids. She stated that a person on a tube feeding should not become dehydrated. She stated that she thought that the nurses would be monitoring his I & O. On 9/10/14, at 1:05pm an interview was conducted with S1RN. She stated that she was one of the ADONs for the facility. She stated that if a doctor has an order for [REDACTED]. She stated that typically nurses don't track the intake for the tube feedings. She stated that we do a Hydration Risk Assessment when a resident is admitted . She stated that if a resident scores 8 or higher, they are at high risk for dehydration. She stated that every day the nurses assess skin turgor and mucous membranes. She stated that typically if a resident is a tube feeder, their water requirements are calculated. She stated that they should not be dehydrated as the water and protein requirements are already being met. She stated that if a resident has an infection and fever then fluid intake should be increased. She stated that if a resident's urine is discolored, the nurse it would document it in the Nurse's Notes. She stated that on 9/4/14, there was nothing documented about the color of Resident #1's urine in the Nurse's Notes. On 9/10/14 at 1:50pm an interview was conducted with the NP for Resident #1. He stated that we don't typically monitor I & O for a resident. For intake Resident #1 received everything through his PEG tube. He stated that he had seen Resident #1's labs of 9/4/14, 11:14pm. He stated that the resident's [MEDICAL CONDITION] and Dehydration could have been caused from Diabetic Ketoic Acidosis (DKA). He stated that it looked like the resident had an infection which could have caused his Glucose to elevate and from that point he developed DKA. He stated that with the resident's Glucose that high, he was sure the resident's Glucose was spilling over into his urine. He stated that the nurse called the on-call physician at 8:30pm on 9/4/14 and it would be up to that doctor to make the call to send the resident to the hospital or treat at the facility. He stated that the on-call physician ordered labs to be obtained from the resident. He stated that this situation could have happened rather fast. He stated that Resident #1's clinical record doesn't state that he was admitted to the facility with any renal problems. He stated that apparently the resident got sicker instead of improving on the antibiotics. He stated that it sounds like the infection put him into DKA and got all of the electrolytes out of whack and the renal function came down. He stated that the on-call physician did not think that the vital signs were of any nature to send him out for treatment. He stated that it is up to the nurse to tell the physician all of the signs and symptoms a resident has so that the best decision can be made in regards to care. On 9/10/14 at 3:35pm an interview was conducted with S4 LPN. She stated that she was the night/evening nurse for Resident #1 on 9/4/14. She stated that Resident #1 had been sick and he had been running an elevated temperature so she obtained his vital signs at 8:30pm. She stated that he looked sweaty and his breathing was labored. She stated that his urine was draining well and it was amber colored and clear. She stated that at 11:45pm when she obtained his vital signs, she called the doctor to get him sent to the hospital. She stated that his vital signs shocked her. She stated that she did not notify the respiratory therapy department of Resident #1's labored and rapid breathing. She stated that she didn't mention to the doctor about the resident having any loose stools or decreased urine output. She stated that when she checked the resident's skin turgor it was less than 3, which was good and his urine out put was normal. She stated that she did not do an accu-check on the resident.

Based on observations, interviews, and record reviews, the facility failed to conduct ongoing assessments for 2 (#2, #5) of 4 (#2, #3, #4, #5) residents reviewed for pressure ulcers. The facility failed to: 1. Ensure weekly skin assessments were completed (#2, #5); 2. Assess a resident's urine for changes (#5); 3. Assess the causes in a change of mental status (#5); 4. Identify pressure ulcers for resident (#2) and changes in a pressure ulcer that warrant notification of the primary care physician (#5) and; 5. Provide ongoing treatment and preventative measures for pressure ulcers (#2, #5). This resulted in an Immediate Jeopardy situation for Residents' #2 and #5 when the facility failed to ensure a system was in place to ensure each resident that was high risk for the development of pressure ulcers received weekly skin assessments to assess for changes in the residents' skin integrity and that changes in wound and urine consistency were reported to the primary care physician. The Immediate Jeopardy began for Resident #2 on 12/31/13 when the resident was found with Stage III pressure ulcers to his right ischium and superior sacrum and a Stage II pressure ulcer to his inferior sacrum. The facility had no knowledge of how Resident #2 had developed Stage II and Stage III pressure ulcers. The Immediate Jeopardy began for Resident #5 on 1/9/14 when the resident's sacral wound was observed to have a foul odor and the nurse failed to notify the primary care physician of the change in the resident's wound. The resident's sacral wound continued to have the foul odor, however, the resident wasn't transferred to the hospital until 1/19/14 at which time she was admitted with a [DIAGNOSES REDACTED]. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 2/20/14 at 4 p.m. The Immediate Jeopardy was removed for both residents on 2/21/14 at 8:15 a.m. when the facility presented an acceptable plan of removal by S1Administrator and S2DON that included: What corrective action(s) are in place for those residents found to be affected by the practice: Resident #2 was admitted on [DATE]. He receives wound care routinely, is on an alternating pressure mattress for his sacral wound and is seen by the in-house wound care doctor weekly. Resident #5 was admitted with wounds on 12/13/13 she went to the hospital on [DATE] and returned on 2/14/2014. Her wounds are being treated by the wound care nurse and she is being monitored weekly during the high risk meetings. Her wounds have been treated by the wound care nurse following her return and are monitored weekly by the wound care doctors contracted by the facility. All wounds in the facility are being monitored by the wound care nurse for reports of progress in the weekly high risk meetings to assess the efficacy of the wound program and continue or change care as necessary. Method(s) used to identify other residents having the potential to be affected by the same practice and what corrective action will be taken: Beginning 2/20/2014, the wound care MD has assessed all residents with pressure ulcers and will in contact with DON or designee on a weekly basis and progress notes will be provided after dictation to the DON or designee. Copies of all treatment orders will be reviewed by DON or RN designee in daily clinical meetings. The orders will be verified by DON and/or RN designee for accurate transcription on TAR. The transcription accuracy monitoring will continue for two weeks and will continue with random monthly audits. DON or designee will monitor every pressure ulcer treatment weekly x 2 months and will continue with random monthly audits. DON or designee will assign body audits to nurses as assigned by med carts and shifts. DON or designee will monitor all body audits weekly x 2 months and will continue with random monthly audits. Wound care audits are being completed for every resident with wounds in the facility by the RN administration and documented using monitoring tools. Body audits are being completed for every resident weekly and new residents are audited and assessed for wounds on admission by the RN nursing staff and documented using monitoring tools. All wounds in the facility are reassessed by the RN administration or RN designee for accuracy in staging and treatment options monthly. All new wounds are brought to the IDT care plan meeting, the weekly High risk meeting and the daily meeting for intervention alternatives. Changes are made to wound care treatments according to MD/wound care doctors orders in the inter-disciplinary meetings and documented as needed. What measures will be put into place or systematic changes will be made to ensure that Practice does not recur: 20% of the facility census will be randomly sampled for body audits and wound documentation are performed monthly by nursing administration to identify inadequacies. Ongoing wound care trainings are then held in conjunction with scheduled monthly QA and are reported to the Administration. Ho How corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The results of the randomly sampled audits will be presented to the Executive Director for inclusion in the QA process and any instances of inadequate nursing treatment will result in disciplinary actions up to and including termination as necessary. Instances of breakdown in the wound care system will be reported during morning meetings and will result in disciplinary action being instituted as appropriate. Results of these audits will monitored as part of the quarterly Quality Assurance process. The deficient practice remains at a scope/severity of actual harm. Findings: Review of the facility's policy entitled, "Pressure Ulcers/Skin Breakdown - Clinical Protocol" included: 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface. Review of the facility's policy entitled, "Pressure Ulcer Risk Assessment" included: Assessment: 3. Monitoring: c. Nurses will conduct skin assessments at least weekly to identify changes. Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The position in which the resident was placed upon completion of the assessment. 4. The name and title of the individual conducting the assessment. 5. Any change in the resident's condition. 6. The condition of the resident's skin... Review of the facility's policy entitled, "Pressure Ulcer Treatment" included: Definitions: Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough. Stage II Pressure Ulcer: Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Resident #5 Review of the clinical record revealed Resident #5 was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident was admitted to the facility as being ventilator dependent and as having a Foley catheter intact to promote sacral wound healing. Review of the Assessment of Pressure Ulcers dated 12/13/13 revealed Resident #5 scored a total of 12. According to the Assessment of Pressure Ulcers, a score of 7-39 indicates the Pressure Risk Protocol should be followed. Review of the admission assessment dated [DATE] revealed in part: Making Self Understood: Understood Mobility: Dependent History of pressure ulcers: Yes: Unchecked; No: Unchecked admitted with pressure or stasis ulcers: Yes: Checked (sacrum wound not noted) Bladder Incontinence: Always Bowel Incontinence: Always Review of the physician's orders [REDACTED]. To sacrum: Clean with wound cleanser, pat dry, apply NPT at 125mmHg continuous. Change dressing every Monday and Thursday. Review of the physician's orders [REDACTED]. D/C previous wound care to sacrum. To sacrum, clean with wound cleanser, pat dry, apply Dakin's 0.25% soaked gauze to wound, cover with clean dry dressing daily. Review of the December 2013 Treatment Records revealed no nursing signatures to indicate that wound care was provided to Resident #5's sacral wound on the following days: 12/16/13-12/25/13. Review of the Weekly Skin Assessment Record for December 2013 revealed no body audits were performed on Resident #5. Review of the December 2013 ADL Tracking Tool by Shift, that included bed mobility, revealed no documentation for dates 12/13/13 - 12/31/13. Review of the physician's orders [REDACTED]. 12/30/13: Refer pt to ___ (Specific Name of Wound Care Center) Wound Care Review of the Nursing Notes for 12/13/13 - 1/17/14 revealed no evidence of a wound assessment upon the resident's admission to the facility. Review of the documentation of ___ (Specific Name of Wound Care Center) Wound Care dated 12/31/13 revealed: Visit Type: Initial Consult Wound #1 Sacrum is a Stage 4 Pressure Ulcer with measurements of 6cm length x 8.5cm width x 0.5cm depth, with an area of 51 sq cm. There is moderate amount of purulent drainage noted which has a mild odor. 30% necrotic tissue to wound bed. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: Pressure Wound Location: Sacrum Stage: IV LxWxD: 8cm length x 8.5cm width x 0.5cm depth Wound Base: 40% granulation; 30% slough; 30% eschar Drainage/Odor: Moderate, Yellow, Odor Present Review of the admission MDS dated [DATE] revealed the resident required one person, total dependence with bed mobility. Further review of the MDS revealed the resident had one stage 1 pressure ulcer upon admit. The MDS further included the resident had a Stage 3 or Stage 4 with length being 7.4, width of 5.2, and depth of 2.0. The ulcer had slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. Review of the Care Plan included: Problem Onset: 12/31/13 Resident has a Stage 3 pressure ulcer to sacrum. Goal & Target Date: Resident's area will decrease in size by 50%. Resident's area will remain free of infection through date 3/31/14. Approaches (in part): - Resident needs wound care as ordered by physician. - Resident needs a full skin evaluation weekly with bath/shower. - Monitor for changes in resident's skin status that may indicate worsening of pressure ulcer and notify the physician. Throughout the onsite investigation on 2/17/14 - 2/21/14, multiple interviews were held with S2DON, S5LPNTX, and S21LPN requesting the facility's nursing assessments related to Resident #5's sacral wound from her admission on 12/13/13 - 12/31/13. Nursing assessments was also requested for the dates of 1/18/14 and 1/19/14. The facility was unable to provide documentation related to the assessment of the resident's sacral wound, or evidence of where the MDS nurse would have obtained the measurements evidenced within the admission MDS dated [DATE]. The facility was also unable to provide the nursing assessments for dates 1/18/14 and 1/19/14. Review of the physician's orders [REDACTED]. U/A with C+S s/p Foley replacement due to dislodgement; C+S if indicated. Review of the Urinalysis results collected on 1/5/14 at 10:05 a.m. revealed the following abnormal results, with the normal results in parenthesis: Clarity: Cloudy (clear) Leukocyte Esterase: Large (Negative) WBC: 5-10 (0-5/hpf) RBC: 5-10 (0-5/hpf) Bacteria: Small (None) Hyaline Cast Urine: Present (None) Triple [MEDICATION NAME] Crystal: Present (None) Review of a fax sent from S26NP on 1/5/14 revealed the fax was received at the facility on 1/5/14 at 10:58 a.m. S26NP made a note on the Urinalysis for Resident #5 dated 1/5/14 collected at 10:05 a.m. The note made by S26NP was, "Is pt on ABX?" There was no response from the facility staff. Review of the Final Culture Report of the urine revealed: Verified 1/9/14 7:03 a.m. Results: > 100,000 CFU/ML Proteus mirabilis Review of the Casemix/Skilled Nursing Notes revealed: 1/4/14: 0900 (9 a.m.): ...Continuously pulling at [MEDICAL CONDITION], PEG tube, and Foley tubing 1/7/14: 2200 (10 p.m.): ...Foley cath patent and draining clear yellow urine... 1/7/14: 8 a.m.: Foley patent and draining amber urine... 1/7/14 4 p.m.: Foley cath patent and intact with clear amber urine... 1/8/14: 10 a.m.: ... Foley patent and draining amber urine... 1/8/14: 1930 (7:30 p.m.): ...clear amber urine to gravity... 1/8/14: 2200 (10 p.m.): ...Foley patent and draining amber urine... 1/9/14 7:45 a.m.: ...Speech mumbled... 1/10/14: 3 p.m.: ...clear dark yellow urine... 1/17/14: 4 p.m.: Pt Accucheck was 494 notified __ (name of S26NP). Review of the Treatment Record for January 2014 revealed wound care services was not provided to Resident #5 on 1/12/14 or 1/18/14. Review of the Weekly Skin Assessment Record for January 2014 revealed the resident did not have weekly skin assessments for 1/15/14, 1/22/14, or 1/29/14. Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/9/14 revealed in part: Chief Complaint: Patient has sacral wound Wound #1 Sacrum is a Stage 4 Pressure Ulcer... Measurements are 9cm length x 9cm width x 1cm depth with an area of 81 sq cm. There is a moderate amount of purulent drainage noted which has a mild odor. Wound bed is 60% slough, 40% granulation. The wound is deteriorating Review of the Weekly Wound Documentation Progress Sheet dated 1/9/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 40% granulation, 60% necrotic Drainage/Odor: Moderate to Heavy; Type: Purulent; Odor: Present Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/16/14 revealed in part: Chief Complaint: Patient has sacral wound ulcer, stage IV. Patient Assessment: Staging care due to: Poor wound progression, significant exudate, necrotic tissue. Wound #1 Sacrum is a Stage 4 Pressure Ulcer. Measurements are 9cm length x 12cm width x 4cm depth with an area of 108 sq cm. There is a moderate amount of purulent drainage noted which has a strong odor. Wound bed is 80% slough, 20% granulation. There is no change noted in wound progression. General Notes: Wound is stable. Bogginess palpated to wound bed. Additional Orders: Aggressive off-loading of these areas at all times. Review of the Weekly Wound Documentation Progress Sheet dated 1/16/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 20% granulation, 80% eschar Drainage/Odor: Moderate; Type: Serosanguineous The facility nurse failed to correctly assess Resident #5's sacral wound, by failing to identify the continuous and worsening purulent drainage from the wound. Review of the Patient Note (Physician's Note) dated 1/17/14 revealed in part: Chief Complaints: Wound Care Doctor called to report wound not improving, foul odor, need ABT. Subjective: Accucheck 490s per nurse Medication Change/Plan: Culture sacrum wound; Start [MEDICATION NAME] 1gm IVPB daily x 14 daily, check CBC/Sed Rate, BMP, X-Ray sacrum, ? osteo Review of the physician's orders [REDACTED]. [MEDICATION NAME] 1gm IVPB daily for 14 days CBC, BMP, Sed Rate in AM X-Ray Sacrum area to check for questionable [DIAGNOSES REDACTED] Culture Sacrum Wound Review of the physician's orders [REDACTED]. K+ 6.6, send to ER for eval and treatment. Review of the hospital's History & Physical with admission of 1/19/14 included: Physical Exam (in part): Extremities: On the sacrum she does have a stage IV sacral decubitus with foul-smelling discharge. Labs (in part): White count is 23.6 with hemoglobin of 9.7, hematocrit of 33.0, platelet count 522. Urinalysis is cloudy with 10-100 WBCs, moderate bacteria and may [MEDICATION NAME] cells. Assessment and Plan (in part): This is an elderly lady who is vent dependent secondary to [MEDICAL CONDITION]. She does present with [MEDICAL CONDITION] secondary to urinary tract infection and infected decubitus ulcers. She will need surgical debridement and also surgery for [REDACTED]. Review of the hospital's Discharge Summary revealed in part: Discharge [DIAGNOSES REDACTED]. [MEDICAL CONDITION] secondary to infected decubitus ulcer. History of Presentation and hospitalization (in part): The patient... was brought to the emergency room for evaluation of [MEDICAL CONDITION] and leukocytosis found on routine blood work... However, she was found to [MEDICAL CONDITION], which was secondary to a large sacral decubitus ulcer, that was having foul smelling discharge. She was started on broad-spectrum antibiotics, [MEDICATION NAME] and [MEDICATION NAME]; Surgical evaluation has been obtained with recommendation for wound debridement and diverticulectomy to promote healing... "Her wound has been stage IV with exposure of sacral bone, with polymicrobial flora." Review of the clinical record revealed Resident #5 returned to the facility on [DATE]. The resident returned to the facility with a [MEDICAL CONDITION], receiving IV antibiotics and with a Wound Vac to the sacral wound. On 2/18/14 at 11 a.m., an observation was made of Resident #5. She was lying in bed on her back with a [MEDICAL CONDITION] a vent. She had urine draining to a urinary bag on the side of the bed. The urine color was clear and yellow. An interview was held with Resident #5 at this time. She was alert and oriented to her self and surroundings. She was able to recall past and present events. Resident #5 stated that she was unable to reposition herself and required assistance from staff to do so. At this time, the resident consented to a skin observation with S5LPNTX and S17LPN repositioning her during the observation. During the observation, the resident was observed to be totally dependent on staff for turning or repositioning. Due to the resident's wound care not being scheduled for this date, observations were made of the surrounding skin with S5LPNTX and S17LPN. The resident was observed (in part) to have a large wound to her sacral area that was covered with a Wound Vac. The Wound Vac had a large amount of serosanguineous (serum and blood) drainage observed. The surrounding skin was intact. The resident tolerated the observation well. An interview was held with S27CNA on 2/19/14 at 9:15 a.m. She stated she routinely cared for Resident #5. She said Resident #5 was admitted to the facility on a vent, with a Foley catheter, and she had a large wound to her buttocks. She said the resident was dependent on staff for turning and repositioning. She said she did not assist the wound care nurse with caring for the wound. She said the resident's wound always drained "a lot". She said the drainage had a "smell" to it, but the nurses were aware of that. She stated the resident's Foley catheter bag was emptied every shift. She said she would notify the nurse if there were any changes in the resident's urine. S27CNA stated she could not recall any changes in the resident's urine. On 2/19/14 at 9:30 a.m., an interview was held with S16LPN. She stated she was a routine nurse for Resident #5. She stated she had cared for Resident #5 since her admission to the facility. She said she worked twelve hour shifts (morning to evening). She stated since admission, Resident #5 had a severe sacral wound. She said she had not assessed the resident's wound, because wound care was supposed to do that. She said the hall nurses were responsible for the weekly body audits. She said there was no assignment for body audits, the nurses completed them as they could throughout the month. She stated if the nurse observed a changed in a resident's status, the nurse should notify the physician. . S16LPN said that all lab results were faxed to the physician. She said if there were negative results that needed to be discussed, the nurse would call the physician. She stated most physicians faxed all orders back to the facility. She said the nurse on the floor observed the fax machine for any faxes. She said if there was an order received, the nurse assigned to the specific resident would carry out the order. S16LPN reviewed the urinalysis results dated 1/5/14 for Resident #5. She verified the results included anomalies. S16LPN verified the nurse practitioner faxed the facility the same day (1/5/14) to inquire if the resident was receiving antibiotics. She reviewed all documentation and stated Resident #5 did not begin antibiotic therapy until 1/17/14 when the primary care physician was notified the resident's sacral wound was infected. She verified the resident was sent to the hospital on [DATE] and admitted with [DIAGNOSES REDACTED]. An interview was held with S7RN on 2/19/14 at 9:50 a.m. S7RN stated she was a routine nurse for Resident #5. She described Resident #5 as being alert and oriented to self and surroundings. She stated the resident was always compliant with care. She stated all labs were faxed to the physician or nurse practitioner. She said usually, the physician or nurse practitioner will write orders on the fax and then fax it back to the facility. She said all nurses retrieve faxes from the fax machine, but each nurse made sure to give the appropriate nurse any faxes that were for their assigned residents. She said she did not recall Resident #5 having a urinary infection in January 2014 that required medical attention. She stated she did not recall any changes in the resident's urine. She reviewed the urinalysis collected 1/5/14 and verified that Resident #5 was positive for a urinary tract infection. She further verified the nurse practitioner had replied via fax questioning the nursing staff if the resident was receiving an antibiotic. After reviewing the nursing notes, S7RN confirmed Resident #5 experienced a change in mental status during the time she was positive with for a urinary tract infection. She said the resident was not usually confused and did not usually pull at [MEDICAL CONDITION] vent tubing. She further stated the resident's urine had changed in color from yellow to amber colored. She confirmed the nursing staff had not followed up with the nurse practitioner regarding the resident's urinalysis results. S7RN stated she was unaware of any changes with the resident's sacral wound. She verified the assigned hall nurses were responsible for performing the residents' weekly body audits. S7RN stated Resident #5's weekly body audits were not performed weekly. On 2/20/14 at 10:30 a.m., an interview was held with S22MDS-CP and S23MDS-CP. S22MDS-CP stated she was responsible for the Care Plan of Resident #5. However, during interview, S23MDS-CP responded to all questions related to Resident #5's Care Plan. S23MDS-CP stated that approaches listed within the Care Plan were discussed during the morning meetings that were held Monday through Friday by the facility's department heads. S23MDS-CP stated that S2DON attended the meetings, but there were no nurses that worked the halls and provided direct care to the residents that attended the meetings. S23MDS-CP further stated that it had been brought to the attention of S2DON that they were not receiving wound care assessments or measurements from the facility's wound care team. An interview was held with S5LPNTX on 2/20/14 at 11 a.m. She said she began employment at the facility on 12/18/13. She stated she had seven years of wound care experience. She said when she began employment at the facility, there was an RN that also worked in the wound care department. She said when she asked the RN about the documentation related to the residents' wound, such as assessments, measurements, etc., she said the RN told her that he did not document such things. She said she told the RN that she had never been employed in a facility that did not document wound assessments or weekly measurements. She said she demanded the wounds start being assessed and measured weekly. She said the documentation did not begin until 12/31/13. She said the RN told her he preferred to handle the paperwork related to the wounds. She said she enjoyed the "hands on" part of the wound care and therefore she performed the actual wound care and made rounds with the doctor from __ (specific name of wound care company). S5LPNTX stated the RN was no longer employed at the facility. She stated she made rounds with the doctor from __ (specific name) Wound Care on 12/31/13 for the first time. She said prior to the date of 12/31/13, there was no evidence of Resident #5's wound being assessed or measured by the facility staff. She verified that on the initial visit, Resident #5's sacral wound was observed as a stage IV pressure wound with purulent drainage. S5LPNTX stated that anytime Dakin's solution was being used in a treatment, the wound had some type of odor. She said she had not notified the resident's primary care physician of the status of the residents' wound at this time. She further verified that she made round with the doctor from __ (specific name) Wound Care on the following visit on 1/9/14, the resident's wound had increased in size and had purulent drainage with a mild odor. She verified the wound treatment did not change and she did not notify the resident's primary care physician. She stated she made rounds with the doctor from __ (specific name) Wound Care on 1/16/14. S5LPNTX verified the wound had increased in size and had significant necrotic tissue observed to the wound. She stated she passed this information on to the RN that was over treatments because she thought he would notify the primary care physician. S5LPNTX verified the primary care physician was not notified until the following day, on 1/17/14, by the physician from __ (specific name) Wound Care. S5LPNTX confirmed Resident #5 was transferred to the hospital on [DATE] and was admitted [MEDICAL CONDITION] secondary to a sacral wound infection. An interview was held with S2DON on 2/20/14 at 12:25 p.m. He stated that presently there was a LPN conducting wound care. He said up until a few days ago, the facility also had a RN on staff in wound care to conduct weekly wound assessments. S2DON verified the RN was supposed to assess a resident's wound weekly and document the findings related to the wound assessment. He stated the RN that was in the wound care position was a new nursing graduate and was trained by the previous wound care nurse, who was no longer employed by the facility. He stated the RN was not sent to any wound care classes prior to being placed in the wound care position. S2DON acknowledged the RN had not performed weekly assessments or conducted wound care as ordered according to the treatment records. He stated that he did not review any of the wound care documentation. S2DON acknowledged that from the first assessment performed on Resident #5's sacral wound on 12/31/13, the resident's wound was noted with an odor. S2DON further acknowledged that on 1/9/14 and 1/16/14, Resident #5's wound was observed with an increase in odor, the wound care treatment did not change, and the primary care physician was not notified. S2DON stated that anytime a nurse observed a change in a resident's status, the nurse was to notify the resident's primary care physician. S2DON stated all evidence related to Resident #5 had been provided. He acknowledged weekly body audits, wound care, and preventative measures were not performed. S2DON acknowledged that Resident #5 had tested positive for a urinary tract infection on 1/5/14 and remained at the facility until 1/19/14 without receiving treatment for [REDACTED]. Resident #2 Review of the clinical record revealed Resident #2 was a [AGE] year old that was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #2 had a history of [REDACTED]. Further review of the clinical record revealed treatments to the resident's bilateral buttocks, Ischial prominences were discontinued on 9/10/13 due to skin being intact (see physician's orders [REDACTED]. Review of the Assessment of Pressure Ulcer Potential form revealed Resident #2 was evaluated by the facility on 1/13/14 as having a score of 11. According to the form this indicated, 7-39 follow Pressure Sore Protocol. Review of the December 2013 Treatment Record included: Head to toe skin assessment once weekly. Left upper and lower buttock: cleanse with wound cleanser, pat dry, apply Santyl ointment, then cover and secure with clean dry dressing daily. - started 12/27/13 Right Ishcium: cleanse with wound cleanser, pat dry, apply [MEDICATION NAME] ointment daily and PRN. - started 12/27/13. Review of the physician's orders [REDACTED].#2's left upper, lower buttock, and right Ishcium. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: blank Wound Location: Right Ischium Stage: III LxWxD: 2cm length x 2cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Superior Sacrum Stage: III LxWxD: 3cm length x 3cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Inferior Sacrum Stage: II LxWxD: 3cm length x 3.5cm width x 0.1cm depth Review of the __ (Name) Wound Care Notes dated 12/31/13: Visit Type: Initial Consult Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 3cm length x 3cm width x 0.1cm depth, with an area of 9 sq cm. Wound bed is 50% slough, 50% granulation. Wound #2 = Inferior Sacrum is a Stage 2 Pressure ulcer. Measurements are 3cm length x 3.5cm width x 0.1cm depth, with an area of 10.5 sq cm. Wound bed is 50% slough, 50% granulation. The periwound skin exhibited maceration. Wound #3 = Right Ischium is a Stage 3 pressure ulcer. Measurements are 2cm length x 2cm width x 0.1cm depth, with an area of 4 sq cm. Wound bed is 50% granulation. Further review of the clinical record revealed no assessments or documentation prior to 12/31/13 related to Resident #2's Stage III right Ischium pressure wound, superior sacrum stage III pressure wound, or the stage II Inferior sacrum wound. Review of the physician's orders [REDACTED]. Throughout the onsite investigation on 2/17/14 - 2/21/14, multiple interview were held with S2DON, S5LPNTX, and S21LPN requesting the facility's nursing assessments and physician's orders [REDACTED]. The facility was unable to provide evidence related to the resident's pressure wounds prior to 12/31/13. Review of the __ (Name) Wound Care Notes dated 1/9/14: Visit Type: Follow Up Visit Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 2.5cm length x 2cm width x 0.1cm depth, with an area of 5 sq cm. Wound #2 = Inferior Sacrum is a Stage 3 Pressure ulcer. Measurements are 1cm length x 4.5cm width x 0.1cm depth, with an area of 4.5 sq cm. Wound bed is 50% slough Wound #3 = Resolved Review of the Weekly Wound Progress Sheet dated 1/9/14 revealed: Type of Wound: Pressure Wound Location: Left

Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standards of quality for 2 (#2, #5) of 4 (#2, #3, #4, #5) residents reviewed for pressure ulcers from a total of 5 sampled residents. The facility failed to: 1. Ensure weekly skin assessments were completed to identify any changes in a resident's skin (#2, #5); 2. Provide thorough and accurate skin assessments to ensure the proper wound care treatment was implemented in a timely manner (#2, #5); 3. Notify the primary care physician of changes in a resident's mental status, urine consistency, and wound odor (#5) and 4. Ensure the resident received the necessary treatment when the facility received urinalysis results that indicated the resident had a urinary tract infection (#5). This resulted in an Immediate Jeopardy situation for Residents' #2 and #5 when the facility failed to ensure a system was in place to ensure each resident that was high risk for the development of pressure ulcers received weekly skin assessments to assess for changes in the residents' skin integrity and that changes in wound and urine consistency were reported to the primary care physician. The Immediate Jeopardy began for Resident #2 on 12/31/13 when the resident was found with Stage III pressure ulcers to his right ischium and superior sacrum and a Stage II pressure ulcer to his inferior sacrum. The facility had no knowledge of how Resident #2 had developed Stage II and Stage III pressure ulcers. The Immediate Jeopardy began for Resident #5 on 1/9/14 when the resident's sacral wound was observed to have a foul odor and the nurse failed to notify the primary care physician of the change in the resident's wound. The resident's sacral wound continued to have the foul odor, however, the resident wasn't transferred to the hospital until 1/19/14 at which time she was admitted with a [DIAGNOSES REDACTED]. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 2/20/14 at 4 p.m. The Immediate Jeopardy was removed for both residents on 2/21/14 at 8:15 a.m. when the facility presented an acceptable plan of removal by S1Administrator and S2DON that included: What corrective action(s) are in place for those residents found to be affected by the practice: Resident #2 was admitted on [DATE]. He receives wound care routinely, is on an alternating pressure mattress for his sacral wound and is seen by the in-house wound care doctor weekly. Resident #5 was admitted with wounds on 12/13/13 she went to the hospital on [DATE] and returned on 2/14/2014. Her wounds are being treated by the wound care nurse and she is being monitored weekly during the high risk meetings. Her wounds have been treated by the wound care nurse following her return and are monitored weekly by the wound care doctors contracted by the facility. All wounds in the facility are being monitored by the wound care nurse for reports of progress in the weekly high risk meetings to assess the efficacy of the wound program and continue or change care as necessary. Method(s) used to identify other residents having the potential to be affected by the same practice and what corrective action will be taken: Beginning 2/20/2014, the wound care MD has assessed all residents with pressure ulcers and will in contact with DON or designee on a weekly basis and progress notes will be provided after dictation to the DON or designee. Copies of all treatment orders will be reviewed by DON or RN designee in daily clinical meetings. The orders will be verified by DON and/or RN designee for accurate transcription on TAR. The transcription accuracy monitoring will continue for two weeks and will continue with random monthly audits. DON or designee will monitor every pressure ulcer treatment weekly x 2 months and will continue with random monthly audits. DON or designee will assign body audits to nurses as assigned by med carts and shifts. DON or designee will monitor all body audits weekly x 2 months and will continue with random monthly audits. Wound care audits are being completed for every resident with wounds in the facility by the RN administration and documented using monitoring tools. Body audits are being completed for every resident weekly and new residents are audited and assessed for wounds on admission by the RN nursing staff and documented using monitoring tools. All wounds in the facility are reassessed by the RN administration or RN designee for accuracy in staging and treatment options monthly. All new wounds are brought to the IDT care plan meeting, the weekly High risk meeting and the daily meeting for intervention alternatives. Changes are made to wound care treatments according to MD/wound care doctors orders in the inter-disciplinary meetings and documented as needed. What measures will be put into place or systematic changes will be made to ensure that Practice does not recur: 20% of the facility census will be randomly sampled for body audits and wound documentation are performed monthly by nursing administration to identify inadequacies. Ongoing wound care trainings are then held in conjunction with scheduled monthly QA and are reported to the Administration. How corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The results of the randomly sampled audits will be presented to the Executive Director for inclusion in the QA process and any instances of inadequate nursing treatment will result in disciplinary actions up to and including termination as necessary. Instances of breakdown in the wound care system will be reported during morning meetings and will result in disciplinary action being instituted as appropriate. Results of these audits will monitored as part of the quarterly Quality Assurance process. The deficient practice remains at a scope/severity of actual harm. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E.Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thing and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team..." Review of the facility's policy entitled, "Pressure Ulcers/Skin Breakdown - Clinical Protocol" included: 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface. Review of the facility's policy entitled, "Pressure Ulcer Risk Assessment" included: Assessment: 3. Monitoring: c. Nurses will conduct skin assessments at least weekly to identify changes. Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The position in which the resident was placed upon completion of the assessment. 4. The name and title of the individual conducting the assessment. 5. Any change in the resident's condition. 6. The condition of the resident's skin... Review of the facility's policy entitled, "Pressure Ulcer Treatment" included: Definitions: Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough. Stage II Pressure Ulcer: Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Resident #5 Review of the clinical record revealed Resident #5 was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident was admitted to the facility as being ventilator dependent and as having a Foley catheter intact to promote sacral wound healing. Review of the Assessment of Pressure Ulcers dated 12/13/13 revealed Resident #5 scored a total of 12. According to the Assessment of Pressure Ulcers, a score of 7-39 indicates the Pressure Risk Protocol should be followed. Review of the admission assessment dated [DATE] revealed in part: Making Self Understood: Understood Mobility: Dependent History of pressure ulcers: Yes: Unchecked; No: Unchecked admitted with pressure or stasis ulcers: Yes: Checked (sacrum wound not noted) Bladder Incontinence: Always Bowel Incontinence: Always Review of the physician's orders [REDACTED]. To sacrum: Clean with wound cleanser, pat dry, apply NPT at 125mmHg continuous. Change dressing every Monday and Thursday. Review of the physician's orders [REDACTED]. D/C previous wound care to sacrum. To sacrum, clean with wound cleanser, pat dry, apply Dakin's 0.25% soaked gauze to wound, cover with clean dry dressing daily. Review of the December 2013 Treatment Records revealed no nursing signatures to indicate that wound care was provided to Resident #5's sacral wound on the following days: 12/16/13-12/25/13. Review of the Weekly Skin Assessment Record for December 2013 revealed no body audits were performed on Resident #5. Review of the December 2013 ADL Tracking Tool by Shift, that included bed mobility, revealed no documentation for dates 12/13/13 - 12/31/13. Review of the physician's orders [REDACTED]. 12/30/13: Refer pt to ___ (Specific Name of Wound Care Center) Wound Care Review of the Nursing Notes for 12/13/13 - 1/17/14 revealed no evidence of a wound assessment upon the resident's admission to the facility. Review of the documentation of ___ (Specific Name of Wound Care Center) Wound Care dated 12/31/13 revealed: Visit Type: Initial Consult Wound #1 Sacrum is a Stage 4 Pressure Ulcer with measurements of 6cm length x 8.5cm width x 0.5cm depth, with an area of 51 sq cm. There is moderate amount of purulent drainage noted which has a mild odor. 30% necrotic tissue to wound bed. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: Pressure Wound Location: Sacrum Stage: IV LxWxD: 8cm length x 8.5cm width x 0.5cm depth Wound Base: 40% granulation; 30% slough; 30% eschar Drainage/Odor: Moderate, Yellow, Odor Present Review of the admission MDS dated [DATE] revealed the resident required one person, total dependence with bed mobility. Further review of the MDS revealed the resident had one stage 1 pressure ulcer upon admit. The MDS further included the resident had a Stage 3 or Stage 4 with length being 7.4, width of 5.2, and depth of 2.0. The ulcer had slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. Review of the Care Plan included: Problem Onset: 12/31/13 Resident has a Stage 3 pressure ulcer to sacrum. Goal & Target Date: Resident's area will decrease in size by 50%. Resident's area will remain free of infection through date 3/31/14. Approaches (in part): - Resident needs wound care as ordered by physician. - Resident needs a full skin evaluation weekly with bath/shower. - Monitor for changes in resident's skin status that may indicate worsening of pressure ulcer and notify the physician. Throughout the onsite investigation on 2/17/14 - 2/21/14, multiple interviews were held with S2DON, S5LPNTX, and S21LPN requesting the facility's nursing assessments related to Resident #5's sacral wound from her admission on 12/13/13 - 12/31/13. Nursing assessments was also requested for the dates of 1/18/14 and 1/19/14. The facility was unable to provide documentation related to the assessment of the resident's sacral wound, or evidence of where the MDS nurse would have obtained the measurements evidenced within the admission MDS dated [DATE]. The facility was also unable to provide the nursing assessments for dates 1/18/14 and 1/19/14. Review of the physician's orders [REDACTED]. U/A with C+S s/p Foley replacement due to dislodgement; C+S if indicated. Review of the Urinalysis results collected on 1/5/14 at 10:05 a.m. revealed the following abnormal results, with the normal results in parenthesis: Clarity: Cloudy (clear) Leukocyte Esterase: Large (Negative) WBC: 5-10 (0-5/hpf) RBC: 5-10 (0-5/hpf) Bacteria: Small (None) Hyaline Cast Urine: Present (None) Triple [MEDICATION NAME] Crystal: Present (None) Review of a fax sent from S26NP on 1/5/14 revealed the fax was received at the facility on 1/5/14 at 10:58 a.m. S26NP made a note on the Urinalysis for Resident #5 dated 1/5/14 collected at 10:05 a.m. The note made by S26NP was, "Is pt on ABX?" There was no response from the facility staff. Review of the Final Culture Report of the urine revealed: Verified 1/9/14 7:03 a.m. Results: > 100,000 CFU/ML Proteus mirabilis Review of the Casemix/Skilled Nursing Notes revealed: 1/4/14: 0900 (9 a.m.): ...Continuously pulling at [MEDICAL CONDITION], PEG tube, and Foley tubing 1/7/14: 2200 (10 p.m.): ...Foley cath patent and draining clear yellow urine... 1/7/14: 8 a.m.: Foley patent and draining amber urine... 1/7/14 4 p.m.: Foley cath patent and intact with clear amber urine... 1/8/14: 10 a.m.: ... Foley patent and draining amber urine... 1/8/14: 1930 (7:30 p.m.): ...clear amber urine to gravity... 1/8/14: 2200 (10 p.m.): ...Foley patent and draining amber urine... 1/9/14 7:45 a.m.: ...Speech mumbled... 1/10/14: 3 p.m.: ...clear dark yellow urine... 1/17/14: 4 p.m.: Pt Accucheck was 494 notified __ (name of S26NP). Review of the Treatment Record for January 2014 revealed wound care services was not provided to Resident #5 on 1/12/14 or 1/18/14. Review of the Weekly Skin Assessment Record for January 2014 revealed the resident did not have weekly skin assessments for 1/15/14, 1/22/14, or 1/29/14. Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/9/14 revealed in part: Chief Complaint: Patient has sacral wound Wound #1 Sacrum is a Stage 4 Pressure Ulcer... Measurements are 9cm length x 9cm width x 1cm depth with an area of 81 sq cm. There is a moderate amount of purulent drainage noted which has a mild odor. Wound bed is 60% slough, 40% granulation. The wound is deteriorating Review of the Weekly Wound Documentation Progress Sheet dated 1/9/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 40% granulation, 60% necrotic Drainage/Odor: Moderate to Heavy; Type: Purulent; Odor: Present Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/16/14 revealed in part: Chief Complaint: Patient has sacral wound ulcer, stage IV. Patient Assessment: Staging care due to: Poor wound progression, significant exudate, necrotic tissue. Wound #1 Sacrum is a Stage 4 Pressure Ulcer. Measurements are 9cm length x 12cm width x 4cm depth with an area of 108 sq cm. There is a moderate amount of purulent drainage noted which has a strong odor. Wound bed is 80% slough, 20% granulation. There is no change noted in wound progression. General Notes: Wound is stable. Bogginess palpated to wound bed. Additional Orders: Aggressive off-loading of these areas at all times. Review of the Weekly Wound Documentation Progress Sheet dated 1/16/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 20% granulation, 80% eschar Drainage/Odor: Moderate; Type: Serosanguineous The facility nurse failed to correctly assess Resident #5's sacral wound, by failing to identify the continuous and worsening purulent drainage from the wound. Review of the Patient Note (Physician's Note) dated 1/17/14 revealed in part: Chief Complaints: Wound Care Doctor called to report wound not improving, foul odor, need ABT. Subjective: Accucheck 490s per nurse Medication Change/Plan: Culture sacrum wound; Start [MEDICATION NAME] 1gm IVPB daily x 14 daily, check CBC/Sed Rate, BMP, X-Ray sacrum, ? osteo Review of the physician's orders [REDACTED]. [MEDICATION NAME] 1gm IVPB daily for 14 days CBC, BMP, Sed Rate in AM X-Ray Sacrum area to check for questionable [DIAGNOSES REDACTED] Culture Sacrum Wound Review of the physician's orders [REDACTED]. K+ 6.6, send to ER for eval and treatment. Review of the hospital's History & Physical with admission of 1/19/14 included: Physical Exam (in part): Extremities: On the sacrum she does have a stage IV sacral decubitus with foul-smelling discharge. Labs (in part): White count is 23.6 with hemoglobin of 9.7, hematocrit of 33.0, platelet count 522. Urinalysis is cloudy with 10-100 WBCs, moderate bacteria and may [MEDICATION NAME] cells. Assessment and Plan (in part): This is an elderly lady who is vent dependent secondary to [MEDICAL CONDITION]. She does present with [MEDICAL CONDITION] secondary to urinary tract infection and infected decubitus ulcers. She will need surgical debridement and also surgery for [REDACTED]. Review of the hospital's Discharge Summary revealed in part: Discharge [DIAGNOSES REDACTED]. [MEDICAL CONDITION] secondary to infected decubitus ulcer. History of Presentation and hospitalization (in part): The patient... was brought to the emergency room for evaluation of [MEDICAL CONDITION] and leukocytosis found on routine blood work... However, she was found to [MEDICAL CONDITION], which was secondary to a large sacral decubitus ulcer, that was having foul smelling discharge. She was started on broad-spectrum antibiotics, [MEDICATION NAME] and [MEDICATION NAME]; Surgical evaluation has been obtained with recommendation for wound debridement and diverticulectomy to promote healing... "Her wound has been stage IV with exposure of sacral bone, with polymicrobial flora." Review of the clinical record revealed Resident #5 returned to the facility on [DATE]. The resident returned to the facility with a [MEDICAL CONDITION], receiving IV antibiotics and with a Wound Vac to the sacral wound. On 2/18/14 at 11 a.m., an observation was made of Resident #5. She was lying in bed on her back with a [MEDICAL CONDITION] a vent. She had urine draining to a urinary bag on the side of the bed. The urine color was clear and yellow. An interview was held with Resident #5 at this time. She was alert and oriented to her self and surroundings. She was able to recall past and present events. Resident #5 stated that she was unable to reposition herself and required assistance from staff to do so. At this time, the resident consented to a skin observation with S5LPNTX and S17LPN repositioning her during the observation. During the observation, the resident was observed to be totally dependent on staff for turning or repositioning. Due to the resident's wound care not being scheduled for this date, observations were made of the surrounding skin with S5LPNTX and S17LPN. The resident was observed (in part) to have a large wound to her sacral area that was covered with a Wound Vac. The Wound Vac had a large amount of serosanguineous (serum and blood) drainage observed. The surrounding skin was intact. The resident tolerated the observation well. An interview was held with S27CNA on 2/19/14 at 9:15 a.m. She stated she routinely cared for Resident #5. She said Resident #5 was admitted to the facility on a vent, with a Foley catheter, and she had a large wound to her buttocks. She said the resident was dependent on staff for turning and repositioning. She said she did not assist the wound care nurse with caring for the wound. She said the resident's wound always drained "a lot". She said the drainage had a "smell" to it, but the nurses were aware of that. She stated the resident's Foley catheter bag was emptied every shift. She said she would notify the nurse if there were any changes in the resident's urine. S27CNA stated she could not recall any changes in the resident's urine. On 2/19/14 at 9:30 a.m., an interview was held with S16LPN. She stated she was a routine nurse for Resident #5. She stated she had cared for Resident #5 since her admission to the facility. She said she worked twelve hour shifts (morning to evening). She stated since admission, Resident #5 had a severe sacral wound. She said she had not assessed the resident's wound, because wound care was supposed to do that. She said the hall nurses were responsible for the weekly body audits. She said there was no assignment for body audits, the nurses completed them as they could throughout the month. She stated if the nurse observed a changed in a resident's status, the nurse should notify the physician. S16LPN said that all lab results were faxed to the physician. She said if there were negative results that needed to be discussed, the nurse would call the physician. She stated most physicians faxed all orders back to the facility. She said the nurse on the floor observed the fax machine for any faxes. She said if there was an order received, the nurse assigned to the specific resident would carry out the order. S16LPN reviewed the urinalysis results dated 1/5/14 for Resident #5. She verified the results included anomalies. S16LPN verified the nurse practitioner faxed the facility the same day (1/5/14) to inquire if the resident was receiving antibiotics. She reviewed all documentation and stated Resident #5 did not begin antibiotic therapy until 1/17/14 when the primary care physician was notified the resident's sacral wound was infected. She verified the resident was sent to the hospital on [DATE] and admitted with [DIAGNOSES REDACTED]. An interview was held with S7RN on 2/19/14 at 9:50 a.m. S7RN stated she was a routine nurse for Resident #5. She described Resident #5 as being alert and oriented to self and surroundings. She stated the resident was always compliant with care. She stated all labs were faxed to the physician or nurse practitioner. She said usually, the physician or nurse practitioner will write orders on the fax and then fax it back to the facility. She said all nurses retrieve faxes from the fax machine, but each nurse made sure to give the appropriate nurse any faxes that were for their assigned residents. She said she did not recall Resident #5 having a urinary infection in January 2014 that required medical attention. She stated she did not recall any changes in the resident's urine. She reviewed the urinalysis collected 1/5/14 and verified that Resident #5 was positive for a urinary tract infection. She further verified the nurse practitioner had replied via fax questioning the nursing staff if the resident was receiving an antibiotic. After reviewing the nursing notes, S7RN confirmed Resident #5 experienced a change in mental status during the time she was positive with for a urinary tract infection. She said the resident was not usually confused and did not usually pull at [MEDICAL CONDITION] vent tubing. She further stated the resident's urine had changed in color from yellow to amber colored. She confirmed the nursing staff had not followed up with the nurse practitioner regarding the resident's urinalysis results. S7RN stated she was unaware of any changes with the resident's sacral wound. She verified the assigned hall nurses were responsible for performing the residents' weekly body audits. S7RN stated Resident #5's weekly body audits were not performed weekly. On 2/20/14 at 10:30 a.m., an interview was held with S22MDS-CP and S23MDS-CP. S22MDS-CP stated she was responsible for the Care Plan of Resident #5. However, during interview, S23MDS-CP responded to all questions related to Resident #5's Care Plan. S23MDS-CP stated that approaches listed within the Care Plan were discussed during the morning meetings that were held Monday through Friday by the facility's department heads. S23MDS-CP stated that S2DON attended the meetings, but there were no nurses that worked the halls and provided direct care to the residents that attended the meetings. S23MDS-CP further stated that it had been brought to the attention of S2DON that they were not receiving wound care assessments or measurements from the facility's wound care team. An interview was held with S5LPNTX on 2/20/14 at 11 a.m. She said she began employment at the facility on 12/18/13. She stated she had seven years of wound care experience. She said when she began employment at the facility, there was an RN that also worked in the wound care department. She said when she asked the RN about the documentation related to the residents' wound, such as assessments, measurements, etc., she said the RN told her that he did not document such things. She said she told the RN that she had never been employed in a facility that did not document wound assessments or weekly measurements. She said she demanded the wounds start being assessed and measured weekly. She said the documentation did not begin until 12/31/13. She said the RN told her he preferred to handle the paperwork related to the wounds. She said she enjoyed the "hands on" part of the wound care and therefore she performed the actual wound care and made rounds with the doctor from __ (specific name of wound care company). S5LPNTX stated the RN was no longer employed at the facility. She stated she made rounds with the doctor from __ (specific name) Wound Care on 12/31/13 for the first time. She said prior to the date of 12/31/13, there was no evidence of Resident #5's wound being assessed or measured by the facility staff. She verified that on the initial visit, Resident #5's sacral wound was observed as a stage IV pressure wound with purulent drainage. S5LPNTX stated that anytime Dakin's solution was being used in a treatment, the wound had some type of odor. She said she had not notified the resident's primary care physician of the status of the residents' wound at this time. She further verified that she made round with the doctor from __ (specific name) Wound Care on the following visit on 1/9/14, the resident's wound had increased in size and had purulent drainage with a mild odor. She verified the wound treatment did not change and she did not notify the resident's primary care physician. She stated she made rounds with the doctor from __ (specific name) Wound Care on 1/16/14. S5LPNTX verified the wound had increased in size and had significant necrotic tissue observed to the wound. She stated she passed this information on to the RN that was over treatments because she thought he would notify the primary care physician. S5LPNTX verified the primary care physician was not notified until the following day, on 1/17/14, by the physician from __ (specific name) Wound Care. S5LPNTX confirmed Resident #5 was transferred to the hospital on [DATE] and was admitted [MEDICAL CONDITION] secondary to a sacral wound infection. An interview was held with S2DON on 2/20/14 at 12:25 p.m. He stated that presently there was a LPN conducting wound care. He said up until a few days ago, the facility also had a RN on staff in wound care to conduct weekly wound assessments. S2DON verified the RN was supposed to assess a resident's wound weekly and document the findings related to the wound assessment. He stated the RN that was in the wound care position was a new nursing graduate and was trained by the previous wound care nurse, who was no longer employed by the facility. He stated the RN was not sent to any wound care classes prior to being placed in the wound care position. S2DON acknowledged the RN had not performed weekly assessments or conducted wound care as ordered according to the treatment records. He stated that he did not review any of the wound care documentation. S2DON acknowledged that from the first assessment performed on Resident #5's sacral wound on 12/31/13, the resident's wound was noted with an odor. S2DON further acknowledged that on 1/9/14 and 1/16/14, Resident #5's wound was observed with an increase in odor, the wound care treatment did not change, and the primary care physician was not notified. S2DON stated that anytime a nurse observed a change in a resident's status, the nurse was to notify the resident's primary care physician. S2DON stated all evidence related to Resident #5 had been provided. He acknowledged weekly body audits, wound care, and preventative measures were not performed. S2DON acknowledged that Resident #5 had tested positive for a urinary tract infection on 1/5/14 and remained at the facility until 1/19/14 without receiving treatment for [REDACTED]. Resident #2 Review of the clinical record revealed Resident #2 was a [AGE] year old that was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #2 had a history of [REDACTED]. Further review of the clinical record revealed treatments to the resident's bilateral buttocks, Ischial prominences were discontinued on 9/10/13 due to skin being intact (see physician's orders [REDACTED]. Review of the December 2013 Treatment Record included: Head to toe skin assessment once weekly. Left upper and lower buttock: cleanse with wound cleanser, pat dry, apply Santyl ointment, then cover and secure with clean dry dressing daily. - started 12/27/13 Right Ishcium: cleanse with wound cleanser, pat dry, apply [MEDICATION NAME] ointment daily and PRN. - started 12/27/13. Review of the physician's orders [REDACTED].#2's left upper, lower buttock, and right Ishcium. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: blank Wound Location: Right Ischium Stage: III LxWxD: 2cm length x 2cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Superior Sacrum Stage: III LxWxD: 3cm length x 3cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Inferior Sacrum Stage: II LxWxD: 3cm length x 3.5cm width x 0.1cm depth Review of the __ (Name) Wound Care Notes dated 12/31/13: Visit Type: Initial Consult Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 3cm length x 3cm width x 0.1cm depth, with an area of 9 sq cm. Wound bed is 50% slough, 50% granulation. Wound #2 = Inferior Sacrum is a Stage 2 Pressure ulcer. Measurements are 3cm length x 3.5cm width x 0.1cm depth, with an area of 10.5 sq cm. Wound bed is 50% slough, 50% granulation. The periwound skin exhibited maceration. Wound #3 = Right Ischium is a Stage 3 pressure ulcer. Mea

Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary care and services to maintain his/her highest practicable physical well-being for 2 (#2, #5) of 4 (#2, #3, #4, #5) residents reviewed for pressure ulcers from a total of 5 sampled residents. The facility failed to: 1. Ensure weekly skin assessments were completed to identify any changes in a resident's skin (#2, #5); 2. Provide thorough and accurate skin assessments to ensure the proper wound care treatment was implemented in a timely manner (#2, #5); 3. Notify the primary care physician of changes in a resident's mental status, urine consistency, and wound odor (#5) and 4. Ensure the resident received the necessary treatment when the facility received urinalysis results that indicated the resident had a urinary tract infection (#5). This resulted in an Immediate Jeopardy situation for Residents' #2 and #5 when the facility failed to ensure a system was in place to ensure each resident that was high risk for the development of pressure ulcers received weekly skin assessments to assess for changes in the residents' skin integrity and that changes in wound and urine consistency were reported to the primary care physician. The Immediate Jeopardy began for Resident #2 on 12/31/13 when the resident was found with Stage III pressure ulcers to his right ischum and superior sacrum and a Stage II pressure ulcer to his inferior sacrum. The facility had no knowledge of how Resident #2 had developed Stage II and Stage III pressure ulcers. The Immediate Jeopardy began for Resident #5 on 1/9/14 when the resident's sacral wound was observed to have a foul odor and the nurse failed to notify the primary care physician of the change in the resident's wound. The resident's sacral wound continued to have the foul odor, however, the resident wasn't transferred to the hospital until 1/19/14 at which time she was admitted with a [DIAGNOSES REDACTED]. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 2/20/14 at 4 p.m. The Immediate Jeopardy was removed for both residents on 2/21/14 at 8:15 a.m. when the facility presented an acceptable plan of removal by S1Administrator and S2DON that included: What corrective action(s) are in place for those residents found to be affected by the practice: Resident #2 was admitted on [DATE]. He receives wound care routinely, is on an alternating pressure mattress for his sacral wound and is seen by the in-house wound care doctor weekly. Resident #5 was admitted with wounds on 12/13/13 she went to the hospital on [DATE] and returned on 2/14/2014. Her wounds are being treated by the wound care nurse and she is being monitored weekly during the high risk meetings. Her wounds have been treated by the wound care nurse following her return and are monitored weekly by the wound care doctors contracted by the facility. All wounds in the facility are being monitored by the wound care nurse for reports of progress in the weekly high risk meetings to assess the efficacy of the wound program and continue or change care as necessary. Method(s) used to identify other residents having the potential to be affected by the same practice and what corrective action will be taken: Beginning 2/20/2014, the wound care MD has assessed all residents with pressure ulcers and will in contact with DON or designee on a weekly basis and progress notes will be provided after dictation to the DON or designee. Copies of all treatment orders will be reviewed by DON or RN designee in daily clinical meetings. The orders will be verified by DON and/or RN designee for accurate transcription on TAR. The transcription accuracy monitoring will continue for two weeks and will continue with random monthly audits. DON or designee will monitor every pressure ulcer treatment weekly x 2 months and will continue with random monthly audits. DON or designee will assign body audits to nurses as assigned by med carts and shifts. DON or designee will monitor all body audits weekly x 2 months and will continue with random monthly audits. Wound care audits are being completed for every resident with wounds in the facility by the RN administration and documented using monitoring tools. Body audits are being completed for every resident weekly and new residents are audited and assessed for wounds on admission by the RN nursing staff and documented using monitoring tools. All wounds in the facility are reassessed by the RN administration or RN designee for accuracy in staging and treatment options monthly. All new wounds are brought to the IDT care plan meeting, the weekly High risk meeting and the daily meeting for intervention alternatives. Changes are made to wound care treatments according to MD/wound care doctors orders in the inter-disciplinary meetings and documented as needed. What measures will be put into place or systematic changes will be made to ensure that Practice does not recur: 20% of the facility census will be randomly sampled for body audits and wound documentation are performed monthly by nursing administration to identify inadequacies. Ongoing wound care trainings are then held in conjunction with scheduled monthly QA and are reported to the Administration. Ho How corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The results of the randomly sampled audits will be presented to the Executive Director for inclusion in the QA process and any instances of inadequate nursing treatment will result in disciplinary actions up to and including termination as necessary. Instances of breakdown in the wound care system will be reported during morning meetings and will result in disciplinary action being instituted as appropriate. Results of these audits will monitored as part of the quarterly Quality Assurance process. The deficient practice remains at a scope/severity of actual harm. Findings: Review of the facility's policy entitled, "Pressure Ulcers/Skin Breakdown - Clinical Protocol" included: 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface. Review of the facility's policy entitled, "Pressure Ulcer Risk Assessment" included: Assessment: 3. Monitoring: c. Nurses will conduct skin assessments at least weekly to identify changes. Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The position in which the resident was placed upon completion of the assessment. 4. The name and title of the individual conducting the assessment. 5. Any change in the resident's condition. 6. The condition of the resident's skin... Review of the facility's policy entitled, "Pressure Ulcer Treatment" included: Definitions: Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough. Stage II Pressure Ulcer: Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Resident #5 Review of the clinical record revealed Resident #5 was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident was admitted to the facility as being ventilator dependent and as having a Foley catheter intact to promote sacral wound healing. Review of the Assessment of Pressure Ulcers dated 12/13/13 revealed Resident #5 scored a total of 12. According to the Assessment of Pressure Ulcers, a score of 7-39 indicates the Pressure Risk Protocol should be followed. Review of the admission assessment dated [DATE] revealed in part: Making Self Understood: Understood Mobility: Dependent History of pressure ulcers: Yes: Unchecked; No: Unchecked admitted with pressure or stasis ulcers: Yes: Checked (sacrum wound not noted) Bladder Incontinence: Always Bowel Incontinence: Always Review of the physician's orders [REDACTED]. To sacrum: Clean with wound cleanser, pat dry, apply NPT at 125mmHg continuous. Change dressing every Monday and Thursday. Review of the physician's orders [REDACTED]. D/C previous wound care to sacrum. To sacrum, clean with wound cleanser, pat dry, apply Dakin's 0.25% soaked gauze to wound, cover with clean dry dressing daily. Review of the December 2013 Treatment Records revealed no nursing signatures to indicate that wound care was provided to Resident #5's sacral wound on the following days: 12/16/13-12/25/13. Review of the Weekly Skin Assessment Record for December 2013 revealed no body audits were performed on Resident #5. Review of the December 2013 ADL Tracking Tool by Shift, that included bed mobility, revealed no documentation for dates 12/13/13 - 12/31/13. Review of the physician's orders [REDACTED]. 12/30/13: Refer pt to ___ (Specific Name of Wound Care Center) Wound Care Review of the Nursing Notes for 12/13/13 - 1/17/14 revealed no evidence of a wound assessment upon the resident's admission to the facility. Review of the documentation of ___ (Specific Name of Wound Care Center) Wound Care dated 12/31/13 revealed: Visit Type: Initial Consult Wound #1 Sacrum is a Stage 4 Pressure Ulcer with measurements of 6cm length x 8.5cm width x 0.5cm depth, with an area of 51 sq cm. There is moderate amount of purulent drainage noted which has a mild odor. 30% necrotic tissue to wound bed. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: Pressure Wound Location: Sacrum Stage: IV LxWxD: 8cm length x 8.5cm width x 0.5cm depth Wound Base: 40% granulation; 30% slough; 30% eschar Drainage/Odor: Moderate, Yellow, Odor Present Review of the admission MDS dated [DATE] revealed the resident required one person, total dependence with bed mobility. Further review of the MDS revealed the resident had one stage 1 pressure ulcer upon admit. The MDS further included the resident had a Stage 3 or Stage 4 with length being 7.4, width of 5.2, and depth of 2.0. The ulcer had slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. Review of the Care Plan included: Problem Onset: 12/31/13 Resident has a Stage 3 pressure ulcer to sacrum. Goal & Target Date: Resident's area will decrease in size by 50%. Resident's area will remain free of infection through date 3/31/14. Approaches (in part): - Resident needs wound care as ordered by physician. - Resident needs a full skin evaluation weekly with bath/shower. - Monitor for changes in resident's skin status that may indicate worsening of pressure ulcer and notify the physician. Throughout the onsite investigation on 2/17/14 - 2/21/14, multiple interviews were held with S2DON, S5LPNTX, and S21LPN requesting the facility's nursing assessments related to Resident #5's sacral wound from her admission on 12/13/13 - 12/31/13. Nursing assessments was also requested for the dates of 1/18/14 and 1/19/14. The facility was unable to provide documentation related to the assessment of the resident's sacral wound, or evidence of where the MDS nurse would have obtained the measurements evidenced within the admission MDS dated [DATE]. The facility was also unable to provide the nursing assessments for dates 1/18/14 and 1/19/14. Review of the physician's orders [REDACTED]. U/A with C+S s/p Foley replacement due to dislodgement; C+S if indicated. Review of the Urinalysis results collected on 1/5/14 at 10:05 a.m. revealed the following abnormal results, with the normal results in parenthesis: Clarity: Cloudy (clear) Leukocyte Esterase: Large (Negative) WBC: 5-10 (0-5/hpf) RBC: 5-10 (0-5/hpf) Bacteria: Small (None) Hyaline Cast Urine: Present (None) Triple [MEDICATION NAME] Crystal: Present (None) Review of a fax sent from S26NP on 1/5/14 revealed the fax was received at the facility on 1/5/14 at 10:58 a.m. S26NP made a note on the Urinalysis for Resident #5 dated 1/5/14 collected at 10:05 a.m. The note made by S26NP was, "Is pt on ABX?" There was no response from the facility staff. Review of the Final Culture Report of the urine revealed: Verified 1/9/14 7:03 a.m. Results: > 100,000 CFU/ML Proteus mirabilis Review of the Casemix/Skilled Nursing Notes revealed: 1/4/14: 0900 (9 a.m.): ...Continuously pulling at [MEDICAL CONDITION], PEG tube, and Foley tubing 1/7/14: 2200 (10 p.m.): ...Foley cath patent and draining clear yellow urine... 1/7/14: 8 a.m.: Foley patent and draining amber urine... 1/7/14 4 p.m.: Foley cath patent and intact with clear amber urine... 1/8/14: 10 a.m.: ... Foley patent and draining amber urine... 1/8/14: 1930 (7:30 p.m.): ...clear amber urine to gravity... 1/8/14: 2200 (10 p.m.): ...Foley patent and draining amber urine... 1/9/14 7:45 a.m.: ...Speech mumbled... 1/10/14: 3 p.m.: ...clear dark yellow urine... 1/17/14: 4 p.m.: Pt Accucheck was 494 notified __ (name of S26NP). Review of the Treatment Record for January 2014 revealed wound care services was not provided to Resident #5 on 1/12/14 or 1/18/14. Review of the Weekly Skin Assessment Record for January 2014 revealed the resident did not have weekly skin assessments for 1/15/14, 1/22/14, or 1/29/14. Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/9/14 revealed in part: Chief Complaint: Patient has sacral wound Wound #1 Sacrum is a Stage 4 Pressure Ulcer... Measurements are 9cm length x 9cm width x 1cm depth with an area of 81 sq cm. There is a moderate amount of purulent drainage noted which has a mild odor. Wound bed is 60% slough, 40% granulation. The wound is deteriorating Review of the Weekly Wound Documentation Progress Sheet dated 1/9/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 40% granulation, 60% necrotic Drainage/Odor: Moderate to Heavy; Type: Purulent; Odor: Present Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/16/14 revealed in part: Chief Complaint: Patient has sacral wound ulcer, stage IV. Patient Assessment: Staging care due to: Poor wound progression, significant exudate, necrotic tissue. Wound #1 Sacrum is a Stage 4 Pressure Ulcer. Measurements are 9cm length x 12cm width x 4cm depth with an area of 108 sq cm. There is a moderate amount of purulent drainage noted which has a strong odor. Wound bed is 80% slough, 20% granulation. There is no change noted in wound progression. General Notes: Wound is stable. Bogginess palpated to wound bed. Additional Orders: Aggressive off-loading of these areas at all times. Review of the Weekly Wound Documentation Progress Sheet dated 1/16/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 20% granulation, 80% eschar Drainage/Odor: Moderate; Type: Serosanguineous The facility nurse failed to correctly assess Resident #5's sacral wound, by failing to identify the continuous and worsening purulent drainage from the wound. Review of the Patient Note (Physician's Note) dated 1/17/14 revealed in part: Chief Complaints: Wound Care Doctor called to report wound not improving, foul odor, need ABT. Subjective: Accucheck 490s per nurse Medication Change/Plan: Culture sacrum wound; Start [MEDICATION NAME] 1gm IVPB daily x 14 daily, check CBC/Sed Rate, BMP, X-Ray sacrum, ? osteo Review of the physician's orders [REDACTED]. [MEDICATION NAME] 1gm IVPB daily for 14 days CBC, BMP, Sed Rate in AM X-Ray Sacrum area to check for questionable [DIAGNOSES REDACTED] Culture Sacrum Wound Review of the physician's orders [REDACTED]. K+ 6.6, send to ER for eval and treatment. Review of the hospital's History & Physical with admission of 1/19/14 included: Physical Exam (in part): Extremities: On the sacrum she does have a stage IV sacral decubitus with foul-smelling discharge. Labs (in part): White count is 23.6 with hemoglobin of 9.7, hematocrit of 33.0, platelet count 522. Urinalysis is cloudy with 10-100 WBCs, moderate bacteria and may [MEDICATION NAME] cells. Assessment and Plan (in part): This is an elderly lady who is vent dependent secondary to [MEDICAL CONDITION]. She does present with [MEDICAL CONDITION] secondary to urinary tract infection and infected decubitus ulcers. She will need surgical debridement and also surgery for [REDACTED]. Review of the hospital's Discharge Summary revealed in part: Discharge [DIAGNOSES REDACTED]. [MEDICAL CONDITION] secondary to infected decubitus ulcer. History of Presentation and hospitalization (in part): The patient... was brought to the emergency room for evaluation of [MEDICAL CONDITION] and leukocytosis found on routine blood work... However, she was found to [MEDICAL CONDITION], which was secondary to a large sacral decubitus ulcer, that was having foul smelling discharge. She was started on broad-spectrum antibiotics, [MEDICATION NAME] and [MEDICATION NAME]; Surgical evaluation has been obtained with recommendation for wound debridement and diverticulectomy to promote healing... "Her wound has been stage IV with exposure of sacral bone, with polymicrobial flora." Review of the clinical record revealed Resident #5 returned to the facility on [DATE]. The resident returned to the facility with a [MEDICAL CONDITION], receiving IV antibiotics and with a Wound Vac to the sacral wound. On 2/18/14 at 11 a.m., an observation was made of Resident #5. She was lying in bed on her back with a [MEDICAL CONDITION] a vent. She had urine draining to a urinary bag on the side of the bed. The urine color was clear and yellow. An interview was held with Resident #5 at this time. She was alert and oriented to her self and surroundings. She was able to recall past and present events. Resident #5 stated that she was unable to reposition herself and required assistance from staff to do so. At this time, the resident consented to a skin observation with S5LPNTX and S17LPN repositioning her during the observation. During the observation, the resident was observed to be totally dependent on staff for turning or repositioning. Due to the resident's wound care not being scheduled for this date, observations were made of the surrounding skin with S5LPNTX and S17LPN. The resident was observed (in part) to have a large wound to her sacral area that was covered with a Wound Vac. The Wound Vac had a large amount of serosanguineous (serum and blood) drainage observed. The surrounding skin was intact. The resident tolerated the observation well. An interview was held with S27CNA on 2/19/14 at 9:15 a.m. She stated she routinely cared for Resident #5. She said Resident #5 was admitted to the facility on a vent, with a Foley catheter, and she had a large wound to her buttocks. She said the resident was dependent on staff for turning and repositioning. She said she did not assist the wound care nurse with caring for the wound. She said the resident's wound always drained "a lot". She said the drainage had a "smell" to it, but the nurses were aware of that. She stated the resident's Foley catheter bag was emptied every shift. She said she would notify the nurse if there were any changes in the resident's urine. S27CNA stated she could not recall any changes in the resident's urine. On 2/19/14 at 9:30 a.m., an interview was held with S16LPN. She stated she was a routine nurse for Resident #5. She stated she had cared for Resident #5 since her admission to the facility. She said she worked twelve hour shifts (morning to evening). She stated since admission, Resident #5 had a severe sacral wound. She said she had not assessed the resident's wound, because wound care was supposed to do that. She said the hall nurses were responsible for the weekly body audits. She said there was no assignment for body audits, the nurses completed them as they could throughout the month. She stated if the nurse observed a changed in a resident's status, the nurse should notify the physician. S16LPN said that all lab results were faxed to the physician. She said if there were negative results that needed to be discussed, the nurse would call the physician. She stated most physicians faxed all orders back to the facility. She said the nurse on the floor observed the fax machine for any faxes. She said if there was an order received, the nurse assigned to the specific resident would carry out the order. S16LPN reviewed the urinalysis results dated 1/5/14 for Resident #5. She verified the results included anomalies. S16LPN verified the nurse practitioner faxed the facility the same day (1/5/14) to inquire if the resident was receiving antibiotics. She reviewed all documentation and stated Resident #5 did not begin antibiotic therapy until 1/17/14 when the primary care physician was notified the resident's sacral wound was infected. She verified the resident was sent to the hospital on [DATE] and admitted with [DIAGNOSES REDACTED]. An interview was held with S7RN on 2/19/14 at 9:50 a.m. S7RN stated she was a routine nurse for Resident #5. She described Resident #5 as being alert and oriented to self and surroundings. She stated the resident was always compliant with care. She stated all labs were faxed to the physician or nurse practitioner. She said usually, the physician or nurse practitioner will write orders on the fax and then fax it back to the facility. She said all nurses retrieve faxes from the fax machine, but each nurse made sure to give the appropriate nurse any faxes that were for their assigned residents. She said she did not recall Resident #5 having a urinary infection in January 2014 that required medical attention. She stated she did not recall any changes in the resident's urine. She reviewed the urinalysis collected 1/5/14 and verified that Resident #5 was positive for a urinary tract infection. She further verified the nurse practitioner had replied via fax questioning the nursing staff if the resident was receiving an antibiotic. After reviewing the nursing notes, S7RN confirmed Resident #5 experienced a change in mental status during the time she was positive with for a urinary tract infection. She said the resident was not usually confused and did not usually pull at [MEDICAL CONDITION] vent tubing. She further stated the resident's urine had changed in color from yellow to amber colored. She confirmed the nursing staff had not followed up with the nurse practitioner regarding the resident's urinalysis results. S7RN stated she was unaware of any changes with the resident's sacral wound. She verified the assigned hall nurses were responsible for performing the residents' weekly body audits. S7RN stated Resident #5's weekly body audits were not performed weekly. On 2/20/14 at 10:30 a.m., an interview was held with S22MDS-CP and S23MDS-CP. S22MDS-CP stated she was responsible for the Care Plan of Resident #5. However, during interview, S23MDS-CP responded to all questions related to Resident #5's Care Plan. S23MDS-CP stated that approaches listed within the Care Plan were discussed during the morning meetings that were held Monday through Friday by the facility's department heads. S23MDS-CP stated that S2DON attended the meetings, but there were no nurses that worked the halls and provided direct care to the residents that attended the meetings. S23MDS-CP further stated that it had been brought to the attention of S2DON that they were not receiving wound care assessments or measurements from the facility's wound care team. An interview was held with S5LPNTX on 2/20/14 at 11 a.m. She said she began employment at the facility on 12/18/13. She stated she had seven years of wound care experience. She said when she began employment at the facility, there was an RN that also worked in the wound care department. She said when she asked the RN about the documentation related to the residents' wound, such as assessments, measurements, etc., she said the RN told her that he did not document such things. She said she told the RN that she had never been employed in a facility that did not document wound assessments or weekly measurements. She said she demanded the wounds start being assessed and measured weekly. She said the documentation did not begin until 12/31/13. She said the RN told her he preferred to handle the paperwork related to the wounds. She said she enjoyed the "hands on" part of the wound care and therefore she performed the actual wound care and made rounds with the doctor from __ (specific name of wound care company). S5LPNTX stated the RN was no longer employed at the facility. She stated she made rounds with the doctor from __ (specific name) Wound Care on 12/31/13 for the first time. She said prior to the date of 12/31/13, there was no evidence of Resident #5's wound being assessed or measured by the facility staff. She verified that on the initial visit, Resident #5's sacral wound was observed as a stage IV pressure wound with purulent drainage. S5LPNTX stated that anytime Dakin's solution was being used in a treatment, the wound had some type of odor. She said she had not notified the resident's primary care physician of the status of the residents' wound at this time. She further verified that she made round with the doctor from __ (specific name) Wound Care on the following visit on 1/9/14, the resident's wound had increased in size and had purulent drainage with a mild odor. She verified the wound treatment did not change and she did not notify the resident's primary care physician. She stated she made rounds with the doctor from __ (specific name) Wound Care on 1/16/14. S5LPNTX verified the wound had increased in size and had significant necrotic tissue observed to the wound. She stated she passed this information on to the RN that was over treatments because she thought he would notify the primary care physician. S5LPNTX verified the primary care physician was not notified until the following day, on 1/17/14, by the physician from __ (specific name) Wound Care. S5LPNTX confirmed Resident #5 was transferred to the hospital on [DATE] and was admitted [MEDICAL CONDITION] secondary to a sacral wound infection. An interview was held with S2DON on 2/20/14 at 12:25 p.m. He stated that presently there was a LPN conducting wound care. He said up until a few days ago, the facility also had a RN on staff in wound care to conduct weekly wound assessments. S2DON verified the RN was supposed to assess a resident's wound weekly and document the findings related to the wound assessment. He stated the RN that was in the wound care position was a new nursing graduate and was trained by the previous wound care nurse, who was no longer employed by the facility. He stated the RN was not sent to any wound care classes prior to being placed in the wound care position. S2DON acknowledged the RN had not performed weekly assessments or conducted wound care as ordered according to the treatment records. He stated that he did not review any of the wound care documentation. S2DON acknowledged that from the first assessment performed on Resident #5's sacral wound on 12/31/13, the resident's wound was noted with an odor. S2DON further acknowledged that on 1/9/14 and 1/16/14, Resident #5's wound was observed with an increase in odor, the wound care treatment did not change, and the primary care physician was not notified. S2DON stated that anytime a nurse observed a change in a resident's status, the nurse was to notify the resident's primary care physician. S2DON stated all evidence related to Resident #5 had been provided. He acknowledged weekly body audits, wound care, and preventative measures were not performed. S2DON acknowledged that Resident #5 had tested positive for a urinary tract infection on 1/5/14 and remained at the facility until 1/19/14 without receiving treatment for [REDACTED]. Resident #2 Review of the clinical record revealed Resident #2 was a [AGE] year old that was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #2 had a history of [REDACTED]. Further review of the clinical record revealed treatments to the resident's bilateral buttocks, Ischial prominences were discontinued on 9/10/13 due to skin being intact (see physician's orders [REDACTED]. Review of the December 2013 Treatment Record included: Head to toe skin assessment once weekly. Left upper and lower buttock: cleanse with wound cleanser, pat dry, apply Santyl ointment, then cover and secure with clean dry dressing daily. - started 12/27/13 Right Ishcium: cleanse with wound cleanser, pat dry, apply [MEDICATION NAME] ointment daily and PRN. - started 12/27/13. Review of the physician's orders [REDACTED].#2's left upper, lower buttock, and right Ishcium. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: blank Wound Location: Right Ischium Stage: III LxWxD: 2cm length x 2cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Superior Sacrum Stage: III LxWxD: 3cm length x 3cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Inferior Sacrum Stage: II LxWxD: 3cm length x 3.5cm width x 0.1cm depth Review of the __ (Name) Wound Care Notes dated 12/31/13: Visit Type: Initial Consult Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 3cm length x 3cm width x 0.1cm depth, with an area of 9 sq cm. Wound bed is 50% slough, 50% granulation. Wound #2 = Inferior Sacrum is a Stage 2 Pressure ulcer. Measurements are 3cm length x 3.5cm width x 0.1cm depth, with an area of 10.5 sq cm. Wound bed is 50% slough, 50% granulation. The periwound skin exhibited maceration. Wound #3 = Right Ischium is a Stage 3 pressure ulcer. Measurements are 2cm length x 2cm width x 0.1cm depth, with an area of 4 sq cm. Wound bed is 50% granulation. Further review of the clinical record revealed no assessments or documentation prior to 12/31/13 related to Resident #2's Stage III right Ischium pressure wound, superior sacrum stage III pressure wound, or the stage II Inferior sacrum wound. Review of the physician's orders [REDACTED]. Throughout the onsite investigation on 2/17/14 - 2/21/14, multiple interview were held with S2DON, S5LPNTX, and S21LPN requesting the facility's nursing assessments and physician's orders [REDACTED]. The facility was unable to provide evidence related to the resident's pressure wounds prior to 12/31/13. Review of the __ (Name) Wound Care Notes dated 1/9/14: Visit Type: Follow Up Visit Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 2.5cm length x 2cm width x 0.1cm depth, with an area of 5 sq cm. Wound #2 = Inferior Sacrum is a Stage 3 Pressure ulcer. Measurements are 1cm length x 4.5cm width x 0.1cm depth, with an area of 4.5 sq cm. Wound bed is 50% slough Wound #3 = Resolved Review of the Weekly Wound Progress Sheet dated 1/9/14 revealed: Type o

Based on observations, interviews, and record reviews, the facility failed to ensure that resident's with pressure ulcers were provided care and services to promote the healing of the ulcers for 2 (#2, #5) of 4 (#2, #3, #4, #5) residents reviewed for pressure ulcers from a total of 5 sampled residents. The facility failed to: 1. Ensure weekly skin assessments were completed (#2, #5); 2. Identify pressure ulcers (#2) and changes in a pressure ulcer that warrant notification of the primary care physician (#5) and 3. Provide ongoing treatment and preventative measures to pressure ulcers (#2, #5) This resulted in an Immediate Jeopardy situation for Residents' #2 and #5 when the facility failed to ensure a system was in place to ensure each resident that was high risk for the development of pressure ulcers received weekly skin assessments to assess for changes in the residents' skin integrity and that changes in wounds were reported to the primary care physician. The Immediate Jeopardy began for Resident #2 on 12/31/13 when the resident was found with Stage III pressure ulcers to his right ischium and superior sacrum and a Stage II pressure ulcer to his inferior sacrum. The facility had no knowledge of how Resident #2 had developed Stage II and Stage III pressure ulcers. The Immediate Jeopardy began for Resident #5 on 1/9/14 when the resident's sacral wound was observed to have a foul odor and the nurse failed to notify the primary care physician of the change in the resident's wound. The resident's sacral wound continued to have the foul odor, however, the resident wasn't transferred to the hospital until 1/19/14 at which time she was admitted with a [DIAGNOSES REDACTED]. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 2/20/14 at 4 p.m. The Immediate Jeopardy was removed for both residents on 2/21/14 at 8:15 a.m. when the facility presented an acceptable plan of removal by S1Administrator and S2DON that included: What corrective action(s) are in place for those residents found to be affected by the practice: Resident #2 was admitted on [DATE]. He receives wound care routinely, is on an alternating pressure mattress for his sacral wound and is seen by the in-house wound care doctor weekly. Resident #5 was admitted with wounds on 12/13/13 she went to the hospital on [DATE] and returned on 2/14/2014. Her wounds are being treated by the wound care nurse and she is being monitored weekly during the high risk meetings. Her wounds have been treated by the wound care nurse following her return and are monitored weekly by the wound care doctors contracted by the facility. All wounds in the facility are being monitored by the wound care nurse for reports of progress in the weekly high risk meetings to assess the efficacy of the wound program and continue or change care as necessary. Method(s) used to identify other residents having the potential to be affected by the same practice and what corrective action will be taken: Beginning 2/20/2014, the wound care MD has assessed all residents with pressure ulcers and will in contact with DON or designee on a weekly basis and progress notes will be provided after dictation to the DON or designee. Copies of all treatment orders will be reviewed by DON or RN designee in daily clinical meetings. The orders will be verified by DON and/or RN designee for accurate transcription on TAR. The transcription accuracy monitoring will continue for two weeks and will continue with random monthly audits. DON or designee will monitor every pressure ulcer treatment weekly x 2 months and will continue with random monthly audits. DON or designee will assign body audits to nurses as assigned by med carts and shifts. DON or designee will monitor all body audits weekly x 2 months and will continue with random monthly audits. Wound care audits are being completed for every resident with wounds in the facility by the RN administration and documented using monitoring tools. Body audits are being completed for every resident weekly and new residents are audited and assessed for wounds on admission by the RN nursing staff and documented using monitoring tools. All wounds in the facility are reassessed by the RN administration or RN designee for accuracy in staging and treatment options monthly. All new wounds are brought to the IDT care plan meeting, the weekly High risk meeting and the daily meeting for intervention alternatives. Changes are made to wound care treatments according to MD/wound care doctors orders in the inter-disciplinary meetings and documented as needed. What measures will be put into place or systematic changes will be made to ensure that Practice does not recur: 20% of the facility census will be randomly sampled for body audits and wound documentation are performed monthly by nursing administration to identify inadequacies. Ongoing wound care trainings are then held in conjunction with scheduled monthly QA and are reported to the Administration. Ho How corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The results of the randomly sampled audits will be presented to the Executive Director for inclusion in the QA process and any instances of inadequate nursing treatment will result in disciplinary actions up to and including termination as necessary. Instances of breakdown in the wound care system will be reported during morning meetings and will result in disciplinary action being instituted as appropriate. Results of these audits will monitored as part of the quarterly Quality Assurance process. The deficient practice remains at a scope/severity of actual harm. Findings: Review of the facility's policy entitled, "Pressure Ulcers/Skin Breakdown - Clinical Protocol" included: 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface. Review of the facility's policy entitled, "Pressure Ulcer Risk Assessment" included: Assessment: 3. Monitoring: c. Nurses will conduct skin assessments at least weekly to identify changes. Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The position in which the resident was placed upon completion of the assessment. 4. The name and title of the individual conducting the assessment. 5. Any change in the resident's condition. 6. The condition of the resident's skin... Review of the facility's policy entitled, "Pressure Ulcer Treatment" included: Definitions: Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed, without slough. Stage II Pressure Ulcer: Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Resident #5 Review of the clinical record revealed Resident #5 was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed the resident was admitted to the facility as being ventilator dependent and as having a Foley catheter intact to promote sacral wound healing. Review of the Assessment of Pressure Ulcers dated 12/13/13 revealed Resident #5 scored a total of 12. According to the Assessment of Pressure Ulcers, a score of 7-39 indicates the Pressure Risk Protocol should be followed. Review of the admission assessment dated [DATE] revealed in part: Making Self Understood: Understood Mobility: Dependent History of pressure ulcers: Yes: Unchecked; No: Unchecked admitted with pressure or stasis ulcers: Yes: Checked (sacrum wound not noted) Bladder Incontinence: Always Bowel Incontinence: Always Review of the physician's orders [REDACTED]. To sacrum: Clean with wound cleanser, pat dry, apply NPT at 125mmHg continuous. Change dressing every Monday and Thursday. Review of the physician's orders [REDACTED]. D/C previous wound care to sacrum. To sacrum, clean with wound cleanser, pat dry, apply Dakin's 0.25% soaked gauze to wound, cover with clean dry dressing daily. Review of the December 2013 Treatment Records revealed no nursing signatures to indicate that wound care was provided to Resident #5's sacral wound on the following days: 12/16/13-12/25/13. Review of the Weekly Skin Assessment Record for December 2013 revealed no body audits were performed on Resident #5. Review of the December 2013 ADL Tracking Tool by Shift, that included bed mobility, revealed no documentation for dates 12/13/13 - 12/31/13. Review of the physician's orders [REDACTED]. 12/30/13: Refer pt to ___ (Specific Name of Wound Care Center) Wound Care Review of the Nursing Notes for 12/13/13 - 1/17/14 revealed no evidence of a wound assessment upon the resident's admission to the facility. Review of the documentation of ___ (Specific Name of Wound Care Center) Wound Care dated 12/31/13 revealed: Visit Type: Initial Consult Wound #1 Sacrum is a Stage 4 Pressure Ulcer with measurements of 6cm length x 8.5cm width x 0.5cm depth, with an area of 51 sq cm. There is moderate amount of purulent drainage noted which has a mild odor. 30% necrotic tissue to wound bed. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: Pressure Wound Location: Sacrum Stage: IV LxWxD: 8cm length x 8.5cm width x 0.5cm depth Wound Base: 40% granulation; 30% slough; 30% eschar Drainage/Odor: Moderate, Yellow, Odor Present Review of the admission MDS dated [DATE] revealed the resident required one person, total dependence with bed mobility. Further review of the MDS revealed the resident had one stage 1 pressure ulcer upon admit. The MDS further included the resident had a Stage 3 or Stage 4 with length being 7.4, width of 5.2, and depth of 2.0. The ulcer had slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. Review of the Care Plan included: Problem Onset: 12/31/13 Resident has a Stage 3 pressure ulcer to sacrum. Goal & Target Date: Resident's area will decrease in size by 50%. Resident's area will remain free of infection through date 3/31/14. Approaches (in part): - Resident needs wound care as ordered by physician. - Resident needs a full skin evaluation weekly with bath/shower. - Monitor for changes in resident's skin status that may indicate worsening of pressure ulcer and notify the physician. Throughout the onsite investigation on 2/17/14 - 2/21/14, multiple interviews were held with S2DON, S5LPNTX, and S21LPN requesting the facility's nursing assessments related to Resident #5's sacral wound from her admission on 12/13/13 - 12/31/13. Nursing assessments was also requested for the dates of 1/18/14 and 1/19/14. The facility was unable to provide documentation related to the assessment of the resident's sacral wound, or evidence of where the MDS nurse would have obtained the measurements evidenced within the admission MDS dated [DATE]. The facility was also unable to provide the nursing assessments for dates 1/18/14 and 1/19/14. Review of the physician's orders [REDACTED]. U/A with C+S s/p Foley replacement due to dislodgement; C+S if indicated. Review of the Urinalysis results collected on 1/5/14 at 10:05 a.m. revealed the following abnormal results, with the normal results in parenthesis: Clarity: Cloudy (clear) Leukocyte Esterase: Large (Negative) WBC: 5-10 (0-5/hpf) RBC: 5-10 (0-5/hpf) Bacteria: Small (None) Hyaline Cast Urine: Present (None) Triple [MEDICATION NAME] Crystal: Present (None) Review of a fax sent from S26NP on 1/5/14 revealed the fax was received at the facility on 1/5/14 at 10:58 a.m. S26NP made a note on the Urinalysis for Resident #5 dated 1/5/14 collected at 10:05 a.m. The note made by S26NP was, "Is pt on ABX?" There was no response from the facility staff. Review of the Final Culture Report of the urine revealed: Verified 1/9/14 7:03 a.m. Results: > 100,000 CFU/ML Proteus mirabilis Review of the Casemix/Skilled Nursing Notes revealed: 1/4/14: 0900 (9 a.m.): ...Continuously pulling at [MEDICAL CONDITION], PEG tube, and Foley tubing 1/7/14: 2200 (10 p.m.): ...Foley cath patent and draining clear yellow urine... 1/7/14: 8 a.m.: Foley patent and draining amber urine... 1/7/14 4 p.m.: Foley cath patent and intact with clear amber urine... 1/8/14: 10 a.m.: ... Foley patent and draining amber urine... 1/8/14: 1930 (7:30 p.m.): ...clear amber urine to gravity... 1/8/14: 2200 (10 p.m.): ...Foley patent and draining amber urine... 1/9/14 7:45 a.m.: ...Speech mumbled... 1/10/14: 3 p.m.: ...clear dark yellow urine... 1/17/14: 4 p.m.: Pt Accucheck was 494 notified __ (name of S26NP). Review of the Treatment Record for January 2014 revealed wound care services was not provided to Resident #5 on 1/12/14 or 1/18/14. Review of the Weekly Skin Assessment Record for January 2014 revealed the resident did not have weekly skin assessments for 1/15/14, 1/22/14, or 1/29/14. Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/9/14 revealed in part: Chief Complaint: Patient has sacral wound Wound #1 Sacrum is a Stage 4 Pressure Ulcer... Measurements are 9cm length x 9cm width x 1cm depth with an area of 81 sq cm. There is a moderate amount of purulent drainage noted which has a mild odor. Wound bed is 60% slough, 40% granulation. The wound is deteriorating Review of the Weekly Wound Documentation Progress Sheet dated 1/9/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 40% granulation, 60% necrotic Drainage/Odor: Moderate to Heavy; Type: Purulent; Odor: Present Review of the __ (Specific Name of Wound Care Center) Wound Care Note dated 1/16/14 revealed in part: Chief Complaint: Patient has sacral wound ulcer, stage IV. Patient Assessment: Staging care due to: Poor wound progression, significant exudate, necrotic tissue. Wound #1 Sacrum is a Stage 4 Pressure Ulcer. Measurements are 9cm length x 12cm width x 4cm depth with an area of 108 sq cm. There is a moderate amount of purulent drainage noted which has a strong odor. Wound bed is 80% slough, 20% granulation. There is no change noted in wound progression. General Notes: Wound is stable. Bogginess palpated to wound bed. Additional Orders: Aggressive off-loading of these areas at all times. Review of the Weekly Wound Documentation Progress Sheet dated 1/16/14 included: Type of Wound: Pressure Wound Location: Sacral Stage: IV LxWxD: 9cm length x 9cm length x 1cm x depth Wound Base: 20% granulation, 80% eschar Drainage/Odor: Moderate; Type: Serosanguineous The facility nurse failed to correctly assess Resident #5's sacral wound, by failing to identify the continuous and worsening purulent drainage from the wound. Review of the Patient Note (Physician's Note) dated 1/17/14 revealed in part: Chief Complaints: Wound Care Doctor called to report wound not improving, foul odor, need ABT. Subjective: Accucheck 490s per nurse Medication Change/Plan: Culture sacrum wound; Start [MEDICATION NAME] 1gm IVPB daily x 14 daily, check CBC/Sed Rate, BMP, X-Ray sacrum, ? osteo Review of the physician's orders [REDACTED]. [MEDICATION NAME] 1gm IVPB daily for 14 days CBC, BMP, Sed Rate in AM X-Ray Sacrum area to check for questionable [DIAGNOSES REDACTED] Culture Sacrum Wound Review of the physician's orders [REDACTED]. K+ 6.6, send to ER for eval and treatment. Review of the hospital's History & Physical with admission of 1/19/14 included: Physical Exam (in part): Extremities: On the sacrum she does have a stage IV sacral decubitus with foul-smelling discharge. Assessment and Plan (in part): This is an elderly lady who is vent dependent secondary to [MEDICAL CONDITION]. She does present with [MEDICAL CONDITION] secondary to an infected decubitus ulcers. She will need surgical debridement and also surgery for [REDACTED]. Review of the hospital's Discharge Summary revealed in part: Discharge [DIAGNOSES REDACTED]. [MEDICAL CONDITION] secondary to infected decubitus ulcer. History of Presentation and hospitalization (in part): The patient... was brought to the emergency room for evaluation of [MEDICAL CONDITION] and leukocytosis found on routine blood work... However, she was found to [MEDICAL CONDITION], which was secondary to a large sacral decubitus ulcer, that was having foul smelling discharge. She was started on broad-spectrum antibiotics, [MEDICATION NAME] and [MEDICATION NAME]; Surgical evaluation has been obtained with recommendation for wound debridement and diverticulectomy to promote healing... "Her wound has been stage IV with exposure of sacral bone, with polymicrobial flora." Review of the clinical record revealed Resident #5 returned to the facility on [DATE]. The resident returned to the facility with a [MEDICAL CONDITION], receiving IV antibiotics and with a Wound Vac to the sacral wound. On 2/18/14 at 11 a.m., an observation was made of Resident #5. She was lying in bed on her back with a [MEDICAL CONDITION] a vent. She had urine draining to a urinary bag on the side of the bed. The urine color was clear and yellow. An interview was held with Resident #5 at this time. She was alert and oriented to her self and surroundings. She was able to recall past and present events. Resident #5 stated that she was unable to reposition herself and required assistance from staff to do so. At this time, the resident consented to a skin observation with S5LPNTX and S17LPN repositioning her during the observation. During the observation, the resident was observed to be totally dependent on staff for turning or repositioning. Due to the resident's wound care not being scheduled for this date, observations were made of the surrounding skin with S5LPNTX and S17LPN. The resident was observed (in part) to have a large wound to her sacral area that was covered with a Wound Vac. The Wound Vac had a large amount of serosanguineous (serum and blood) drainage observed. The surrounding skin was intact. The resident tolerated the observation well. An interview was held with S27CNA on 2/19/14 at 9:15 a.m. She stated she routinely cared for Resident #5. She said Resident #5 was admitted to the facility on a vent, with a Foley catheter, and she had a large wound to her buttocks. She said the resident was dependent on staff for turning and repositioning. She said she did not assist the wound care nurse with caring for the wound. She said the resident's wound always drained "a lot". She said the drainage had a "smell" to it, but the nurses were aware of that. She stated the resident's Foley catheter bag was emptied every shift. She said she would notify the nurse if there were any changes in the resident's urine. S27CNA stated she could not recall any changes in the resident's urine. On 2/19/14 at 9:30 a.m., an interview was held with S16LPN. She stated she was a routine nurse for Resident #5. She stated she had cared for Resident #5 since her admission to the facility. She said she worked twelve hour shifts (morning to evening). She stated since admission, Resident #5 had a severe sacral wound. She said she had not assessed the resident's wound, because wound care was supposed to do that. She said the hall nurses were responsible for the weekly body audits. She said there was no assignment for body audits, the nurses completed them as they could throughout the month. She stated if the nurse observed a changed in a resident's status, the nurse should notify the physician. S16LPN said that all lab results were faxed to the physician. She said if there were negative results that needed to be discussed, the nurse would call the physician. She stated most physicians faxed all orders back to the facility. She said the nurse on the floor observed the fax machine for any faxes. She said if there was an order received, the nurse assigned to the specific resident would carry out the order. S16LPN reviewed the urinalysis results dated 1/5/14 for Resident #5. She verified the results included anomalies. S16LPN verified the nurse practitioner faxed the facility the same day (1/5/14) to inquire if the resident was receiving antibiotics. She reviewed all documentation and stated Resident #5 did not begin antibiotic therapy until 1/17/14 when the primary care physician was notified the resident's sacral wound was infected. She verified the resident was sent to the hospital on [DATE] and admitted with [DIAGNOSES REDACTED]. An interview was held with S7RN on 2/19/14 at 9:50 a.m. S7RN stated she was a routine nurse for Resident #5. She described Resident #5 as being alert and oriented to self and surroundings. She stated the resident was always compliant with care. She stated all labs were faxed to the physician or nurse practitioner. She said usually, the physician or nurse practitioner will write orders on the fax and then fax it back to the facility. She said all nurses retrieve faxes from the fax machine, but each nurse made sure to give the appropriate nurse any faxes that were for their assigned residents. She said she did not recall Resident #5 having a urinary infection in January 2014 that required medical attention. She stated she did not recall any changes in the resident's urine. She reviewed the urinalysis collected 1/5/14 and verified that Resident #5 was positive for a urinary tract infection. She further verified the nurse practitioner had replied via fax questioning the nursing staff if the resident was receiving an antibiotic. After reviewing the nursing notes, S7RN confirmed Resident #5 experienced a change in mental status during the time she was positive with for a urinary tract infection. She said the resident was not usually confused and did not usually pull at [MEDICAL CONDITION] vent tubing. She further stated the resident's urine had changed in color from yellow to amber colored. She confirmed the nursing staff had not followed up with the nurse practitioner regarding the resident's urinalysis results. S7RN stated she was unaware of any changes with the resident's sacral wound. She verified the assigned hall nurses were responsible for performing the residents' weekly body audits. S7RN stated Resident #5's weekly body audits were not performed weekly. On 2/20/14 at 10:30 a.m., an interview was held with S22MDS-CP and S23MDS-CP. S22MDS-CP stated she was responsible for the Care Plan of Resident #5. However, during interview, S23MDS-CP responded to all questions related to Resident #5's Care Plan. S23MDS-CP stated that approaches listed within the Care Plan were discussed during the morning meetings that were held Monday through Friday by the facility's department heads. S23MDS-CP stated that S2DON attended the meetings, but there were no nurses that worked the halls and provided direct care to the residents that attended the meetings. S23MDS-CP further stated that it had been brought to the attention of S2DON that they were not receiving wound care assessments or measurements from the facility's wound care team. An interview was held with S5LPNTX on 2/20/14 at 11 a.m. She said she began employment at the facility on 12/18/13. She stated she had seven years of wound care experience. She said when she began employment at the facility, there was an RN that also worked in the wound care department. She said when she asked the RN about the documentation related to the residents' wound, such as assessments, measurements, etc., she said the RN told her that he did not document such things. She said she told the RN that she had never been employed in a facility that did not document wound assessments or weekly measurements. She said she demanded the wounds start being assessed and measured weekly. She said the documentation did not begin until 12/31/13. She said the RN told her he preferred to handle the paperwork related to the wounds. She said she enjoyed the "hands on" part of the wound care and therefore she performed the actual wound care and made rounds with the doctor from __ (specific name of wound care company). S5LPNTX stated the RN was no longer employed at the facility. She stated she made rounds with the doctor from __ (specific name) Wound Care on 12/31/13 for the first time. She said prior to the date of 12/31/13, there was no evidence of Resident #5's wound being assessed or measured by the facility staff. She verified that on the initial visit, Resident #5's sacral wound was observed as a stage IV pressure wound with purulent drainage. S5LPNTX stated that anytime Dakin's solution was being used in a treatment, the wound had some type of odor. She said she had not notified the resident's primary care physician of the status of the residents' wound at this time. She further verified that she made round with the doctor from __ (specific name) Wound Care on the following visit on 1/9/14, the resident's wound had increased in size and had purulent drainage with a mild odor. She verified the wound treatment did not change and she did not notify the resident's primary care physician. She stated she made rounds with the doctor from __ (specific name) Wound Care on 1/16/14. S5LPNTX verified the wound had increased in size and had significant necrotic tissue observed to the wound. She stated she passed this information on to the RN that was over treatments because she thought he would notify the primary care physician. S5LPNTX verified the primary care physician was not notified until the following day, on 1/17/14, by the physician from __ (specific name) Wound Care. S5LPNTX confirmed Resident #5 was transferred to the hospital on [DATE] and was admitted [MEDICAL CONDITION] secondary to a sacral wound infection. An interview was held with S2DON on 2/20/14 at 12:25 p.m. He stated that presently there was a LPN conducting wound care. He said up until a few days ago, the facility also had a RN on staff in wound care to conduct weekly wound assessments. S2DON verified the RN was supposed to assess a resident's wound weekly and document the findings related to the wound assessment. He stated the RN that was in the wound care position was a new nursing graduate and was trained by the previous wound care nurse, who was no longer employed by the facility. He stated the RN was not sent to any wound care classes prior to being placed in the wound care position. S2DON acknowledged the RN had not performed weekly assessments or conducted wound care as ordered according to the treatment records. He stated that he did not review any of the wound care documentation. S2DON acknowledged that from the first assessment performed on Resident #5's sacral wound on 12/31/13, the resident's wound was noted with an odor. S2DON further acknowledged that on 1/9/14 and 1/16/14, Resident #5's wound was observed with an increase in odor, the wound care treatment did not change, and the primary care physician was not notified. S2DON stated that anytime a nurse observed a change in a resident's status, the nurse was to notify the resident's primary care physician. S2DON stated all evidence related to Resident #5 had been provided. He acknowledged weekly body audits, wound care, and preventative measures were not performed. S2DON further acknowledged that Resident #5 was transferred to the hospital on [DATE] and admitted with a [DIAGNOSES REDACTED]. Resident #2 Review of the clinical record revealed Resident #2 was a [AGE] year old that was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #2 had a history of [REDACTED]. Further review of the clinical record revealed treatments to the resident's bilateral buttocks, Ischial prominences were discontinued on 9/10/13 due to skin being intact (see physician's orders [REDACTED]. Review of the Assessment of Pressure Ulcer Potential form revealed Resident #2 was evaluated by the facility on 1/13/14 as having a score of 11. According to the form this indicated, 7-39 follow Pressure Sore Protocol. Review of the December 2013 Treatment Record included: Head to toe skin assessment once weekly. Left upper and lower buttock: cleanse with wound cleanser, pat dry, apply Santyl ointment, then cover and secure with clean dry dressing daily. - started 12/27/13 Right Ishcium: cleanse with wound cleanser, pat dry, apply [MEDICATION NAME] ointment daily and PRN. - started 12/27/13. Review of the physician's orders [REDACTED].#2's left upper, lower buttock, and right Ishcium. Review of the Weekly Wound Documentation Progress Sheet dated 12/31/13 revealed: Type of Wound: blank Wound Location: Right Ischium Stage: III LxWxD: 2cm length x 2cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Superior Sacrum Stage: III LxWxD: 3cm length x 3cm width x 0.1cm depth Type of Wound: Pressure Wound Location: Inferior Sacrum Stage: II LxWxD: 3cm length x 3.5cm width x 0.1cm depth Review of the __ (Name) Wound Care Notes dated 12/31/13: Visit Type: Initial Consult Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 3cm length x 3cm width x 0.1cm depth, with an area of 9 sq cm. Wound bed is 50% slough, 50% granulation. Wound #2 = Inferior Sacrum is a Stage 2 Pressure ulcer. Measurements are 3cm length x 3.5cm width x 0.1cm depth, with an area of 10.5 sq cm. Wound bed is 50% slough, 50% granulation. The periwound skin exhibited maceration. Wound #3 = Right Ischium is a Stage 3 pressure ulcer. Measurements are 2cm length x 2cm width x 0.1cm depth, with an area of 4 sq cm. Wound bed is 50% granulation. Further review of the clinical record revealed no assessments or documentation prior to 12/31/13 related to Resident #2's Stage III right Ischium pressure wound, superior sacrum stage III pressure wound, or the stage II Inferior sacrum wound. Review of the physician's orders [REDACTED]. Throughout the onsite investigation on 2/17/14 - 2/21/14, multiple interview were held with S2DON, S5LPNTX, and S21LPN requesting the facility's nursing assessments and physician's orders [REDACTED]. The facility was unable to provide evidence related to the resident's pressure wounds prior to 12/31/13. Review of the __ (Name) Wound Care Notes dated 1/9/14: Visit Type: Follow Up Visit Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 2.5cm length x 2cm width x 0.1cm depth, with an area of 5 sq cm. Wound #2 = Inferior Sacrum is a Stage 3 Pressure ulcer. Measurements are 1cm length x 4.5cm width x 0.1cm depth, with an area of 4.5 sq cm. Wound bed is 50% slough Wound #3 = Resolved Review of the Weekly Wound Progress Sheet dated 1/9/14 revealed: Type of Wound: Pressure Wound Location: Left Buttock #1 Stage: III LxWxD: 2.5cm length x 2cm width x 0.1cm depth Review of the __ (Name) Wound Care Notes dated 1/16/14: Visit Type: Follow Up Visit Wound #1 = Superior Sacrum is an acute Stage 3 pressure ulcer. Measurements are 2.5cm length x 2cm width x 0.1cm depth, with an area of 5 sq cm. Wound #2 = Inferior Sacrum is a Stage 3 Pressure ulcer. Measurements are 2cm length x 2cm width x 0.1cm depth, with an area of 4 sq cm. Wound bed is 50% slough

Based on observations, interviews, and record reviews, the facility to be administered in a manner that enabled it to effectively and efficiently utilize its resources to maintain the highest practicable physical well-being of each resident for 2 (#2, #5) of 4 (#2, #3, #4, #5) residents reviewed for pressure ulcers from a total of 5 sampled residents. The facility failed to: 1. Ensure weekly skin assessments were completed to identify any changes in a resident's skin (#2, #5); 2. Provide thorough and accurate skin assessments to ensure the proper wound care treatment was implemented in a timely manner (#2, #5); 3. Notify the primary care physician of changes in a resident's mental status, urine consistency, and wound odor (#5) and 4. Ensure the resident received the necessary treatment when the facility received urinalysis results that indicated the resident had a urinary tract infection (#5). This resulted in an Immediate Jeopardy situation for Residents' #2 and #5 when the facility failed to ensure a system was in place to ensure each resident that was high risk for the development of pressure ulcers received weekly skin assessments to assess for changes in the residents' skin integrity and that changes in wound and urine consistency were reported to the primary care physician. The Immediate Jeopardy began for Resident #2 on 12/31/13 when the resident was found with Stage III pressure ulcers to his right ischium and superior sacrum and a Stage II pressure ulcer to his inferior sacrum. The facility had no knowledge of how Resident #2 had developed Stage II and Stage III pressure ulcers. The Immediate Jeopardy began for Resident #5 on 1/9/14 when the resident's sacral wound was observed to have a foul odor and the nurse failed to notify the primary care physician of the change in the resident's wound. The resident's sacral wound continued to have the foul odor, however, the resident wasn't transferred to the hospital until 1/19/14 at which time she was admitted with a [DIAGNOSES REDACTED]. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 2/20/14 at 4 p.m. The Immediate Jeopardy was removed for both residents on 2/21/14 at 8:15 a.m. when the facility presented an acceptable plan of removal by S1Administrator and S2DON that included: What corrective action(s) are in place for those residents found to be affected by the practice: Resident #2 was admitted on [DATE]. He receives wound care routinely, is on an alternating pressure mattress for his sacral wound and is seen by the in-house wound care doctor weekly. Resident #5 was admitted with wounds on 12/13/13 she went to the hospital on [DATE] and returned on 2/14/2014. Her wounds are being treated by the wound care nurse and she is being monitored weekly during the high risk meetings. Her wounds have been treated by the wound care nurse following her return and are monitored weekly by the wound care doctors contracted by the facility. All wounds in the facility are being monitored by the wound care nurse for reports of progress in the weekly high risk meetings to assess the efficacy of the wound program and continue or change care as necessary. Method(s) used to identify other residents having the potential to be affected by the same practice and what corrective action will be taken: Beginning 2/20/2014, the wound care MD has assessed all residents with pressure ulcers and will in contact with DON or designee on a weekly basis and progress notes will be provided after dictation to the DON or designee. Copies of all treatment orders will be reviewed by DON or RN designee in daily clinical meetings. The orders will be verified by DON and/or RN designee for accurate transcription on TAR. The transcription accuracy monitoring will continue for two weeks and will continue with random monthly audits. DON or designee will monitor every pressure ulcer treatment weekly x 2 months and will continue with random monthly audits. DON or designee will assign body audits to nurses as assigned by med carts and shifts. DON or designee will monitor all body audits weekly x 2 months and will continue with random monthly audits. Wound care audits are being completed for every resident with wounds in the facility by the RN administration and documented using monitoring tools. Body audits are being completed for every resident weekly and new residents are audited and assessed for wounds on admission by the RN nursing staff and documented using monitoring tools. All wounds in the facility are reassessed by the RN administration or RN designee for accuracy in staging and treatment options monthly. All new wounds are brought to the IDT care plan meeting, the weekly High risk meeting and the daily meeting for intervention alternatives. Changes are made to wound care treatments according to MD/wound care doctors orders in the inter-disciplinary meetings and documented as needed. What measures will be put into place or systematic changes will be made to ensure that Practice does not recur: 20% of the facility census will be randomly sampled for body audits and wound documentation are performed monthly by nursing administration to identify inadequacies. Ongoing wound care trainings are then held in conjunction with scheduled monthly QA and are reported to the Administration. Ho How corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The results of the randomly sampled audits will be presented to the Executive Director for inclusion in the QA process and any instances of inadequate nursing treatment will result in disciplinary actions up to and including termination as necessary. Instances of breakdown in the wound care system will be reported during morning meetings and will result in disciplinary action being instituted as appropriate. Results of these audits will monitored as part of the quarterly Quality Assurance process. The deficient practice remains at a scope/severity of actual harm. Findings: Cross reference F272, F281, F309, and F314. An interview was held with S2DON on 2/20/14 at 12:25 p.m. He said up until a few days ago, the facility also had a RN on staff in wound care to conduct weekly wound assessments, but that presently there was a LPN conducting wound care. S2DON verified the RN was supposed to assess a resident's wound weekly and document the findings related to the wound assessment. He stated the RN that was in the wound care position was a new nursing graduate and was trained by the previous wound care nurse, who was no longer employed by the facility. He stated the RN was not sent to any wound care classes prior to being placed in the wound care position. S2DON acknowledged the RN had not performed weekly assessments or conducted wound care as ordered according to the treatment records. S2DON stated that he did not review any of the wound care documentation. S2DON acknowledged that from the first assessment performed on Resident #5's sacral wound on 12/31/13, the resident's wound was noted with an odor. S2DON further acknowledged that on 1/9/14 and 1/16/14, Resident #5's wound was observed with an increase in odor, the wound care treatment did not change, and the primary care physician was not notified. S2DON stated that anytime a nurse observed a change in a resident's status, the nurse was to notify the resident's primary care physician. S2DON stated all evidence related to Resident #5 had been provided. He acknowledged weekly body audits, wound care, and preventative measures were not performed. S2DON acknowledged that Resident #5 had tested positive for a urinary tract infection on 1/5/14 and remained at the facility until 1/19/14 without receiving treatment for [REDACTED]. S2DON acknowledged that Resident #2 developed stage II and III pressure wounds and there was no evidence of a break in skin integrity leading up to those wounds. He stated that the CNAs were supposed to report any changes in a resident's skin to the nurse, and the nurse was then to report it to the wound care nurse. He acknowledged the facility had no evidence of how Resident #2 had developed stage 2 and 3 sacral wounds without facility intervention. S2DON stated the facility had not identified any issues with assessments or pressure ulcers.

Based on observation, record review and interview, the facility failed to provide professional standards of quality by failing to ensure that nursing staff implemented infection control procedures for a potentially infectious organism for a resident(#132) diagnosed with [REDACTED]. The facility further failed to ensure that the other 41 residents on Hall A (#4, #5, #8, #12, #13, #15, #19, #26, #29, #32, #38, #42, #46, #51, #54, #55, #59, #63, #64, #68, #72, #74, #83, #88, #89, #92, #102, #104, #106, #108, #109, #110, #123, #128, #134, #140, #147, #153, #154, #157, #160) from a total census of 121 residents were not subjected to staff who did not follow proper isolation precautions, before entering their rooms, after leaving a resident's room with a known infectious organism. The facility failed to: 1) Ensure nursing staff follow proper hand washing techniques before, during and after performing care for a resident on Contact Isolation(#132) for [MEDICAL CONDITION] Infection 2) Ensure nursing staff wore proper protective clothing before entering a room to provide care for a resident who was on contact isolation. (#132) for [MEDICAL CONDITION] on 11/26/12 - 11/30/12 3) Ensure nursing staff implemented appropriate isolation precautions from 11/5/12 to 11/9/12 for a resident whose stool culture was reported positive for[DIAGNOSES REDACTED] on 11/512. (#132) 4) Ensure nursing staff implemented correct hand washing procedures to prevent spread of [MEDICAL CONDITION] on 11/28/12. 5) Ensure nursing staff followed MD orders for contact isolation on 11/26/12. 6) Ensure nursing staff implemented and followed the facility's policy and procedure for infection control correctly to prevent spread of [MEDICAL CONDITION] infection. Resident #32, #68 and #140 were placed in Immediate Jeopardy on 11/26/12 when S17CNA showered the residents in a shower room/chair without disinfecting them according to CDC guidelines after it was used by Resident #132. Resident #132 had orders for Contact Isolation related to a [DIAGNOSES REDACTED].#132 ' s room and also not wearing Personal Protective Equipment( PPE) while in the resident ' s room who was in Contact Isolation for [MEDICAL CONDITION]. The Administrator was notified of the Immediate Jeopardy on 11/26/12 at 5:28 p.m. A Plan of Removal was presented by the Administrator which read: ...This morning after this was identified, the nursing staff was in-serviced on [MEDICAL CONDITION] and Isolation, including obtaining orders for isolation to begin and not discontinuing until ordered by the Medical Doctor(MD). All shifts will be in-serviced today. ...The Housekeeping Department Head in-serviced the housekeeping staff today as well regarding communication with staff when a resident is in isolation to ensure that supplies are gathered for [MEDICAL CONDITION] cleaning procedure (2 biohazardous bags, including 2 trash liners, 1 bottle of Clorox germicidal bleach mixture, 1 fresh mop head, 1 fresh ...... mop). To dress in proper PPE before entering the [MEDICAL CONDITION] room (Put on isolation gown, shoe covers, hair cap, face mask, disposable gloves). Collect trash and soiled linen(collect all personal items and place in a double lined trash bag, collect all trash in room and place in double lined trash bag, place all soiled linen in a trash liner that is then placed inside a yellow biohazard bag). Clean and disinfect [MEDICAL CONDITION] room with bleach spray, clean and disinfect bathroom with bleach spray, mop the entire room with disinfectant with bleach, dispose of mop head in double lined bag for disposal. Exit clean room and discard all PPE (see attached). The shower room was cleaned by housekeeping with Clorox cleanup cleaner with bleach spray formula for 10 minutes of exposure time. The housekeeping manager cleaned the shower room again with the Bleach mixture of 8 parts water and 1 part bleach for a minimum of 10 minutes exposure time. The resident's room was cleaned with the Bleach disinfecting wipes. The shower aides will use Bleach spray which consists of 8 parts water with 1 part bleach, this is a 9:1 solution, for at least 10 minutes of exposure time after showering each resident and all shower aides will be in-serviced regarding using the Clorox germicidal bleach mixture and that it must be discarded after 24 hours. For the 3 resident's placed in Jeopardy: The MD was notified of the potential exposure. Orders were received to monitor these residents for symptoms including watery stools, fever, loss of appetite, nausea, stomach pains. ... The family members were notified of the potential exposure. For any other resident with [MEDICAL CONDITION]: Nursing and CNA staffs were in-serviced regarding[DIAGNOSES REDACTED], isolation precautions, potential for spread of infection and observing isolation until the MD discontinues. Also housekeeping staff have been in-serviced for proper cleaning of the rooms and observing isolation policies. The bleach solution will be used for the cleaning of the rooms for residents with[DIAGNOSES REDACTED] and cleaning of the showers between each resident. Shower aides were in-serviced regarding using bleach solution which consists of 8 parts water with 1 part bleach this is a 9:1 solution and will be prepared by the housekeeping supervisor or designee each morning. They were also in-serviced that the solution expires after 24 hours via the phone on 11/27/12 by DON and ADON. The housekeeping supervisor and housekeeping staff will be in-serviced on the Clorox germicidal bleach mixture. The housekeeping supervisor and housekeeping staff will be in-serviced that the Clorox germicidal bleach mixture should be mixed daily using 1 part bleach to 8 parts of water to achieve a 1:9 solution. Housekeeping staff will complete in-services by Wednesday, November 28. The nursing staff and housekeeping staff will complete in-services by December 1, 2012 for the following: the Bleach Mixture is only good for 24 hours and should be disposed of after 24 hours. The spray bottles will be replenished with a new batch of solution with 1 part bleach and 8 parts water and will be labeled with the date and time each morning. Use of bleach spray in the shower between showering each resident. The Immediate Jeopardy was removed on 11/27/12 at 4:15 p.m. when the surveyors confirmed that the facility's plan of removal to clean and disinfect the shower chair/room was implemented. The deficient practice remains at a level 2 for a potential for more than minimal harm for any resident that can potentially become infected with [MEDICAL CONDITION]. The A hall residents (#4, #5, #8, #12, #13, #15, #19, #26, #29, #32, #38, #42, #46, #51, #54, #55, #59, #63, #64, #68, #72, #74, #83, #88, #89, #92, #102, #104, #106, #108, #109, #110, #123, #128, #134, #140, #147, #153, #154, #157, #160) were placed in Immediate Jeopardy on 11/28/12 at 7:37 a.m., when S8LPN entered Resident #132's room who had [MEDICAL CONDITION] without a gown, mask and foot covers. S8LPN was observed touching the resident covers and upper extremities. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. The Administrator was notified of the Immediate Jeopardy on12/12/12 at 12:05 p.m. A plan of removal was presented by the Administrator which read: 1. How corrective actions were accomplished for those residents found to have been affected by the stated deficient practice: ?The LPN involved has been inserviced and counseled regarding the break in policy for isolation residents. ?The resident is currently hospitalized for [REDACTED]. 2. Any resident with [MEDICAL CONDITION] has the potential to be affected by the stated deficient practice: ?There are no other residents in the facility with D-Diff. ?There are not residents in the facility who require isolation. 3. Measures put in place that will be made to ensure that the stated deficient practice will not recur: ?Staff have been inservice for Isolation Policies and Proper Handwashing. ?Hand Sanitizer is on all med carts and in the common areas. ?Nursing Administration will identify any resident who has [MEDICAL CONDITION] and review Isolation and Handwashing policies with staff at that time. ?Infection Control nurse will check Isolation cart and educate staff in the event that resident is positive for [MEDICAL CONDITION]. 4. How the facility plans to monitor its performance to make sure that solutions are sustained: ?Any resident who is positive for [MEDICAL CONDITION] will be identified by Nursing Administration. ?Staff will be re-educated regarding Isolation and Handwashing in the event a resident is identified as having [MEDICAL CONDITION]. ?The DON or designee will monitor staff practice for Isolation and Handwashing on a regular basis. ?Any staff member who fails to follow Isolation and Handwashing guidelines will be counseled and re-educated. Continued breaks in compliance will result in disciplinary action. 5. Corrective Action is completed as of 12/12/12. Inservices were stared on 12/10/12 and have been completed. The Immediate jeopardy was removed on 12/04/12 at 09:15 a.m. when the resident was admitted to a local hospital. The deficient practice remains at a level 2 for a potential for more than minimal harm for residents on the A hall. Findings: Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1.. 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6.. Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and working as a member of the interdisciplinary health care team..." Review of the three facility's policies received revealed the following in part: a. Infection Control Policy Title: [MEDICAL CONDITIONS] Policy: dated 04/01/07 The facility is committed to providing a safe and healthy environment for resident's and to minimize or prevent the spread of infections. Purpose To prevent transmission of [MEDICAL CONDITION] to other residents. Procedure: 1. Prevention of [MEDICAL CONDITION]: 1.1 Wash resident ' s hands 1.1.1 When soiled with feces; 1.1.2 After they handle items which may be contaminated (e.g., commode) 1.2. Employees wash their hands: 1.2.1 After incontinence care; 1.2.2 After helping toilet a resident; 1.2.3 After handling potentially contaminated items; 1.2.8 After removal of personal protective clothing. 1.6 Disinfect shower area... 2. Interventions: 2.3 Use standard precautions except for residents with diarrhea associated with [MEDICAL CONDITION]. In this case, use contact precautions. b. [MEDICAL CONDITION] Policy (Revised date: April 2010) Policy Statement Preventive measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [MEDICAL CONDITION] (to prevent transmission of [MEDICAL CONDITION] to others). Policy Interpretation and Implementation 6. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant handwashing with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of [MEDICAL CONDITION] spores from hands. 7. Due to the persistence of [MEDICAL CONDITION] spores for prolonged periods of time, all fecally-contaminated articles must be considered potentially infectious and disinfected with a disinfecting agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution... 9. Steps toward prevention and early intervention include: ...c. Hand washing of staff and residents... f. Disinfection of items with fecal soiling (e.g., bedpans, commode chairs, bedrails, etc.) using a disinfectant agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution)... c. Isolation Policy (Revised October 2010) Policy Statement Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions or Airborne Precautions... Policy Interpretation and Implementation ...4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Control Coordinator discontinues them, which should occur after pertinent criteria for discontinuation are met... 5. When Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room... c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room... On 11/26/12 at 8:15 a.m. an observation was noted of a 3 compartment plastic storage device sitting in hallway with gowns, gloves and protection plus briefs near Resident #132's room. Further observation was made of Resident #132 lying in the bed in her room with the door open. No sign was noted alerting staff/family to see the nurse. On 11/26/12 at 8:19 a.m. interview was conducted with S15LPN. She verified Resident #132 was on contact isolation precautions. She said she told the CNAs to take the contact isolation precautions sign down; because the resident had finished taking her antibiotics. She stated she told the CNAs she would get an order to discontinue isolation precautions on that day. She said "Right now, technically, the resident was still on contact isolation but that it was on her To do list to get an order to discontinue it". She said the CNAs took the sign down this morning for contact isolation, but confirmed there was no order to do so. She stated she had been on vacation so she didn't really know if the physician wanted the resident to remain on contact isolation precautions. Review of Resident #132's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent Minimum Data Set(MDS) with an Assessment Review Date of 10/27/12 revealed the resident's Brief Interview for Mental Status(BIMS) Total Summary Score in Section C-Cognitive Pattern C0500 to be a 10; Moderately Impaired. Review of the Resident #132's Physician order [REDACTED]. 11/5/12 1:30 p.m. Stool x 1 for [MEDICAL CONDITION](Diff) 11/6/12 at 12:00 noon [MEDICATION NAME] 500 milligrams(mg) per peg every(q) 6 hours times 2 weeks for [MEDICAL CONDITION]. 11/9/12 Contact Isolation for [MEDICAL CONDITION]. Review of Resident #132's Laboratory Report dated 11/5/12 revealed the resident was positive for [MEDICAL CONDITION]. Review of Resident 132's Comprehensive Plan of Care for Infection revealed the following in part: Approaches: Encourage good clean hygiene techniques to avoid cross-contamination, especially hand washing before meals and after bowel movements... On 11/26/12 at 10:27 a.m., an interview was conducted with S16CNA. She stated Resident #132 had been having loose, foul smelling stools 3 and 4 times a day since they put her on contact isolation and it never got better. She said that she asked S15LPN was the resident still on contact isolation when she came to work this morning, because they had been wearing gowns, gloves and a mask. S15LPN told her Resident #132 finished her antibiotics and to take the contact isolation sign down. She said she removed the sign and the biohazard carts, but left the 3 compartment cart outside the door. She said that she only wore gloves when she went in the resident's room this morning and that she had not worn a gown, mask or shoe covers. On 11/26/12 at 10:29 a.m. an interview was conducted with S15LPN. She stated that she called Resident #132's physician and obtained an order for [REDACTED]. On 11/26/12 at 10:30 a.m. an observation noted the staff going in and out of the resident's room with the door left open without protective equipment. Review of Resident #132's clinical record revealed an order on 11/26/12 at 9:00 a.m. for Stool x 1. Continue contact isolation until [MEDICAL CONDITION] was resolved. On 11/26/12 at 11:07 a.m. an interview was conducted with S17CNA. She said that S15LPN informed her Resident #132 was not on contact isolation. She confirmed she had 2 clear bags of clean linen with her when she entered Resident #132's room. She said she left 1 bag in Resident #132's room and she took the other clear bag of linen from Resident #132's room to another resident's room. She confirmed that she was not supposed to take clean linen out of Resident #132's room who was on contact isolation to another resident's room. She also said she put a gown on Resident #132 and transported her to the community bathroom and gave her a shower. She said that after the resident's bath, she took the resident's gown back down the hall to her room; without it being in a double lined trash bag and put it in her hamper for her family to wash. On 11/26/12 at 2:01 p.m., an interview was conducted with S7Infection Control Nurse. She stated that once the facility found a resident was on contact isolation, the protocol was to institute contact precautions that day, but confirmed the facility obtained a positive lab result for [MEDICAL CONDITION] for Resident #132 on 11/5/12; [MEDICATION NAME] 500 mg for 11/6/12 and an order for [REDACTED]. On 11/26/12 2:28 p.m. an interview was conducted with S15LPN. She confirmed the facility received lab results on 11/5/12 confirming that Resident #132 was positive for [MEDICAL CONDITION] and an order was not obtained until 11/9/12 to place the resident on contact isolation. On 11/28/12 at 7:37 a.m.,. an observation was made of S8LPN entering Resident #132's room without a gown, mask and foot covers. S8LPN was observed touching the resident covers and upper extremities. Further observation noted that the resident's family member was touching and leaning over the resident without a gown, gloves, mask or shoe covers. The family member then retrieved a cell phone out of his pocket and placed in up to his ear and exited the room, without washing his hands. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. On 11/28/12 at 7:39 a.m. an interview was conducted with S8LPN. She stated that she was the staff nurse taking care of Resident #132 and did not know the resident was still on contact isolation. She said that resident's family member told her that she still had [MEDICAL CONDITION] and confirmed she did not wear the gown, mask, foot covers or gloves while touching the resident, nor did she wash her hands when she came out of the resident's room. On 11/28/12 at 7:40 a.m. an observation was made of S20LPN entering into Resident #132's room without a gown, mask, gloves and shoe covers conversing with the resident's family member. On 11/28/2012 at 7:43 a.m. an interview was conducted with S20LPN. She stated that she did not know Resident #132 was on contact isolation and confirmed she did not put a gown, gloves and shoe covers before entering the resident's room and was supposed to. On 11/28/12 at 3:12 p.m., an interview was conducted with S2DON. She confirmed the facility staff was not implementing contact isolation precautions on 11/26/12 because S15LPN told the CNAs that Resident #132 was no longer on contact isolation before obtaining a discontinue order. S2DON said an order should have been obtained before S15LPN informed staff the resident was no longer on Contact Isolation and verified that it was not. She stated staff nurses should have known not to enter the resident's room without PPE on because there was a sign placed on Resident #132's door on 11/26/12 after an order was obtained to continue contact isolation precautions; notifying them to come to the nurses station before entering the resident's room. She said the nursing staff were supposed to be putting on a disposable gown, gloves, mask and shoe covers before entering the resident's room on contact isolation and removing the protective equipment before exiting. She also acknowledged the nursing staff was supposed to wash their hands before and after providing care for to the resident and confirmed they were not following the facility's policies and procedures as noted above.

Based on observations, interview, and record review the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection to 42 residents on Hall A (#4, #5, #8, #12, #13, #15, #19, #26, #29, #32, #38, #42, #46, #51, #54, #55, #59, #63, #64, #68, #72, #74, #83, #88, #89, #92, #102, #104, #106, #108, #109, #110, #123, #128, #132, #134, #140, #147, #153, #154, #157, #160) from a total census of 121 residents listed on the Resident Census and Condition document by failing to: 1) Disinfect the shower chair/shower room according to Centers for Disease Control(CDC) Standards on 11/26/12 after showering a resident (#132) who was in Contact Isolation due to Clostridium Difficile (C Diff) prior to showering other residents (#32, #68, #140) 2) Ensure staff and family follow proper hand washing techniques before, during and after having contact and performing care for a resident on Contact Isolation(#132) for Clostridium Difficile Infection 3) Ensure staff wore proper protective clothing before entering a room to provide care for a resident who was on Contact Isolation. (#132) for Clostridium Difficile on 11/26/12 - 11/30/12 4) Ensure staff was inserviced on the proper cleaning agent required to disinfect the community shower after showering a resident with[DIAGNOSES REDACTED]. (#132) 5) Ensure staff did not transport clean linen out of a resident's room with[DIAGNOSES REDACTED] (#132) and take it to another resident's room for usage. 6) Implement appropriate isolation precautions from 11/5/12 to 11/9/12 for a resident whose stool culture was reported positive for[DIAGNOSES REDACTED] on 11/5/12. (#132) 7) Ensure staff implemented correct hand washing procedures to prevent spread of[DIAGNOSES REDACTED] on 11/28/12. 8) Ensure staff followed MD orders for contact isolation on 11/26/12 9) Monitor staff to ensure the facility's policy and procedure for infection control was implemented correctly to prevent spread of[DIAGNOSES REDACTED] infection. Resident #32, #68 and #140 were placed in Immediate Jeopardy on 11/26/12 when S17CNA showered the residents in a shower room/chair without disinfecting them according to CDC guidelines after it was used by Resident #132. Resident #132 had orders for Contact Isolation related to a [DIAGNOSES REDACTED].#132 ' s room and also not wearing Personal Protective Equipment( PPE) while in the resident ' s room who was in Contact Isolation for[DIAGNOSES REDACTED]. The Administrator was notified of the Immediate Jeopardy on 11/26/12 at 5:28 p.m. A Plan of Removal was presented by the Administrator which read: ...This morning after this was identified, the nursing staff was in-serviced on[DIAGNOSES REDACTED] and Isolation, including obtaining orders for isolation to begin and not discontinuing until ordered by the Medical Doctor(MD). All shifts will be in-serviced today. ...The Housekeeping Department Head in-serviced the housekeeping staff today as well regarding communication with staff when a resident is in isolation to ensure that supplies are gathered for[DIAGNOSES REDACTED] cleaning procedure (2 biohazardous bags, including 2 trash liners, 1 bottle of Clorox germicidal bleach mixture, 1 fresh mop head, 1 fresh ...... mop). To dress in proper PPE before entering the[DIAGNOSES REDACTED] room (Put on isolation gown, shoe covers, hair cap, face mask, disposable gloves). Collect trash and soiled linen(collect all personal items and place in a double lined trash bag, collect all trash in room and place in double lined trash bag, place all soiled linen in a trash liner that is then placed inside a yellow biohazard bag). Clean and disinfect[DIAGNOSES REDACTED] room with bleach spray, clean and disinfect bathroom with bleach spray, mop the entire room with disinfectant with bleach, dispose of mop head in double lined bag for disposal. Exit clean room and discard all PPE (see attached). The shower room was cleaned by housekeeping with Clorox cleanup cleaner with bleach spray formula for 10 minutes of exposure time. The housekeeping manager cleaned the shower room again with the Bleach mixture of 8 parts water and 1 part bleach for a minimum of 10 minutes exposure time. The resident's room was cleaned with the Bleach disinfecting wipes. The shower aides will use Bleach spray which consists of 8 parts water with 1 part bleach, this is a 9:1 solution, for at least 10 minutes of exposure time after showering each resident and all shower aides will be in-serviced regarding using the Clorox germicidal bleach mixture and that it must be discarded after 24 hours. For the 3 resident's placed in Jeopardy: The MD was notified of the potential exposure. Orders were received to monitor these residents for symptoms including watery stools, fever, loss of appetite, nausea, stomach pains. ... The family members were notified of the potential exposure. For any other resident with[DIAGNOSES REDACTED]: Nursing and CNA staffs were in-serviced regarding[DIAGNOSES REDACTED], isolation precautions, potential for spread of infection and observing isolation until the MD discontinues. Also housekeeping staff have been in-serviced for proper cleaning of the rooms and observing isolation policies. The bleach solution will be used for the cleaning of the rooms for residents with[DIAGNOSES REDACTED] and cleaning of the showers between each resident. Shower aides were in-serviced regarding using bleach solution which consists of 8 parts water with 1 part bleach this is a 9:1 solution and will be prepared by the housekeeping supervisor or designee each morning. They were also in-serviced that the solution expires after 24 hours via the phone on 11/27/12 by DON and ADON. The housekeeping supervisor and housekeeping staff will be in-serviced on the Clorox germicidal bleach mixture. The housekeeping supervisor and housekeeping staff will be in-serviced that the Clorox germicidal bleach mixture should be mixed daily using 1 part bleach to 8 parts of water to achieve a 1:9 solution. Housekeeping staff will complete in-services by Wednesday, November 28. The nursing staff and housekeeping staff will complete in-services by December 1, 2012 for the following: the Bleach Mixture is only good for 24 hours and should be disposed of after 24 hours. The spray bottles will be replenished with a new batch of solution with 1 part bleach and 8 parts water and will be labeled with the date and time each morning. Use of bleach spray in the shower between showering each resident. The Immediate Jeopardy was removed on 11/27/12 at 4:15 p.m. when the surveyors confirmed that the facility's plan of removal to clean and disinfect the shower chair/room was implemented. The deficient practice remains at a level 2 for a potential for more than minimal harm for any resident that can potentially become infected with[DIAGNOSES REDACTED]icile. The A hall residents (#4, #5, #8, #12, #13, #15, #19, #26, #29, #32, #38, #42, #46, #51, #54, #55, #59, #63, #64, #68, #72, #74, #83, #88, #89, #92, #102, #104, #106, #108, #109, #110, #123, #128, #134, #140, #147, #153, #154, #157, #160) were placed in Immediate Jeopardy on 11/28/12 at 7:37 a.m., when S8LPN entered Resident #132's room who had[DIAGNOSES REDACTED] without a gown, mask and foot covers. S8LPN was observed touching the resident covers and upper extremities. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. The Administrator was notified of the Immediate Jeopardy on12/12/12 at 12:05 p.m. A plan of removal was presented by the Administrator which read: 1. How corrective actions were accomplished for those residents found to have been affected by the stated deficient practice: ?The LPN involved has been inserviced and counseled regarding the break in policy for isolation residents. ?The resident is currently hospitalized for [REDACTED]. 2. Any resident with[DIAGNOSES REDACTED] has the potential to be affected by the stated deficient practice: ?There are no other residents in the facility with D-Diff. ?There are not residents in the facility who require isolation. 3. Measures put in place that will be made to ensure that the stated deficient practice will not recur: ?Staff have been inservice for Isolation Policies and Proper Handwashing. ?Hand Sanitizer is on all med carts and in the common areas. ?Nursing Administration will identify any resident who has[DIAGNOSES REDACTED] and review Isolation and Handwashing policies with staff at that time. ?Infection Control nurse will check Isolation cart and educate staff in the event that resident is positive for[DIAGNOSES REDACTED]. 4. How the facility plans to monitor its performance to make sure that solutions are sustained: ?Any resident who is positive for[DIAGNOSES REDACTED] will be identified by Nursing Administration. ?Staff will be re-educated regarding Isolation and Handwashing in the event a resident is identified as having[DIAGNOSES REDACTED]. ?The DON or designee will monitor staff practice for Isolation and Handwashing on a regular basis. ?Any staff member who fails to follow Isolation and Handwashing guidelines will be counseled and re-educated. Continued breaks in compliance will result in disciplinary action. 5. Corrective Action is completed as of 12/12/12. Inservices were stared on 12/10/12 and have been completed. The Immediate jeopardy was removed on 12/04/12 at 09:15 a.m. when the resident was admitted to a local hospital. The deficient practice remains at a level 2 for a potential for more than minimal harm for residents on the A hall. Findings: Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1.. 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6.. Review of the three facility's policies received revealed the following in part: a. Infection Control Policy Title: Clostridium Difficile (C-diff) Policy: dated 04/01/07 The facility is committed to providing a safe and healthy environment for resident's and to minimize or prevent the spread of infections. Purpose To prevent transmission of Clostridium Difficile(C-diff) to other residents. Procedure: 1.Prevention of Clostridium Difficile: 1.1 Wash resident ' s hands 1.1.1 When soiled with feces; 1.1.2 After they handle items which may be contaminated (e.g., commode) 1.2. Employees wash their hands: 1.2.1 After incontinence care; 1.2.2 After helping toilet a resident; 1.2.3 After handling potentially contaminated items; 1.2.8 After removal of personal protective clothing. 1.6 Disinfect shower area... 2. Interventions: 2.3 Use standard precautions except for residents with diarrhea associated with Clostridium Difficile. In this case, use contact precautions. b. Clostridium Difficile Policy (Revised date: April 2010) Policy Statement Preventive measures will be taken to prevent the occurrence of Clostridium Difficile infections among residents and precautions will be taken while caring for residents with Clostridium Dificile (to prevent transmission of Clostridium Dificile to others). Policy Interpretation and Implementation 6. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant handwashing with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of Clostridium Difficile spores from hands. 7. Due to the persistence of Clostridium Difficile spores for prolonged periods of time, all fecally-contaminated articles must be considered potentially infectious and disinfected with a disinfecting agent recommended for Clostridium Difficile (e.g., household bleach and water solution... 9. Steps toward prevention and early intervention include: ...c. Hand washing of staff and residents... f. Disinfection of items with fecal soiling (e.g., bedpans, commode chairs, bedrails, etc.) using a disinfectant agent recommended for Clostridium Difficile (e.g., household bleach and water solution)... c. Isolation Policy (Revised October 2010) Policy Statement Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions or Airborne Precautions... Policy Interpretation and Implementation ...4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Control Coordinator discontinues them, which should occur after pertinent criteria for discontinuation are met... 5. When Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room... c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room... On 11/26/12 at 8:15 a.m. an observation was noted of a 3 compartment plastic storage device sitting in hallway with gowns, gloves and protection plus briefs near Resident #132's room. Further observation was made of Resident #132 lying in the bed in her room with the door open. No sign was noted alerting staff/family to see the nurse. On 11/26/12 at 8:19 a.m. interview was conducted with S15LPN. She verified Resident #132 was on contact isolation precautions. She said she told the CNAs to take the contact isolation precautions sign down; because the resident had finished taking her antibiotics. She stated she told the CNAs she would get an order to discontinue isolation precautions on that day. She said "Right now, technically, the resident was still on contact isolation but that it was on her To do list to get an order to discontinue it". She said the CNAs took the sign down this morning for contact isolation, but confirmed there was no order to do so. She stated she had been on vacation so she didn't really know if the physician wanted the resident to remain on contact isolation precautions. Review of Resident #132's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent Minimum Data Set(MDS) with an Assessment Review Date of 10/27/12 revealed the resident's Brief Interview for Mental Status(BIMS) Total Summary Score in Section C-Cognitive Pattern C0500 to be a 10; Moderately Impaired. Review of the Resident #132's Physician order [REDACTED]. 11/5/12 1:30 p.m. Stool x 1 for[DIAGNOSES REDACTED]icile(Diff) 11/6/12 at 12:00 noon [MEDICATION NAME] 500 milligrams(mg) per peg every(q) 6 hours times 2 weeks for[DIAGNOSES REDACTED]. 11/9/12 Contact Isolation for[DIAGNOSES REDACTED]. Review of Resident #132's Laboratory Report dated 11/5/12 revealed the resident was positive for[DIAGNOSES REDACTED]icile. Review of Resident 132's Comprehensive Plan of Care for Infection revealed the following in part: Problem, Need, Strength, Potential Concern: Stool As evidenced by: Abnormal Labs Related to Resident diagnosed of: Clostridium Difficile Goal: Resident will have no signs or symptoms of active infection as evidenced by:[DIAGNOSES REDACTED] stool culture Resident will maintain adequate hydration as evidenced by moist mucous membranes, supple skin turgor, stable lab values as prescribed until resolution of infectious process. Approaches: ...Post antibiotic therapy lab work as ordered and report results to physician... Encourage good clean hygiene techniques to avoid cross-contamination, especially hand washing before meals and after bowel movements... On 11/26/12 at 10:27 a.m., an interview was conducted with S16CNA. She stated Resident #132 had been having loose, foul smelling stools 3 and 4 times a day since they put her on contact isolation and it never got better. She said that she asked S15LPN was the resident still on contact isolation when she came to work this morning, because they had been wearing gowns, gloves and a mask. S15LPN told her Resident #132 finished her antibiotics and to take the contact isolation sign down. She said she removed the sign and the biohazard carts, but left the 3 compartment cart outside the door. She said that she only wore gloves when she went in the resident's room this morning and that she had not worn a gown, mask or shoe covers. On 11/26/12 at 10:29 a.m. an interview was conducted with S15LPN. She stated that she called Resident #132's physician and obtained an order for [REDACTED]. On 11/26/12 at 10:30 a.m. an observation noted the staff going in and out of the resident's room with the door left open without protective equipment. Review of Resident #132's clinical record revealed an order on 11/26/12 at 9:00 a.m. for Stool x 1. Continue contact isolation until[DIAGNOSES REDACTED] was resolved. On 11/26/12 at 10:54 a.m., an observation was made of S16CNA entering Resident #132's room with a pillow case without protective equipment and exiting without washing her hands. On 11/26/12 at 11:04 a.m. an observation was made of a S17CNA entering Resident #132's room without protective equipment on with 2 clear bags of clean linen. Further observation noted S17CNA exiting the resident's room, without washing her hands, with 1 bag of clean linen and entering another resident's room. On 11/26/12 at 11:07 a.m. an interview was conducted with S17CNA. She said that S15LPN informed her Resident #132 was not on contact isolation. She confirmed she had 2 clear bags of clean linen with her when she entered Resident #132's room. She said she left 1 bag in Resident #132's room and she took the other clear bag of linen from Resident #132's room to another resident's room. She confirmed that she was not supposed to take clean linen out of Resident #132's room who was on contact isolation to another resident's room. She also said she put a gown on Resident #132 and transported her to the community bathroom and gave her a shower. She said that after the resident's bath, she took the resident's gown back down the hall to her room; without it being in a double lined trash bag and put it in her hamper for her family to wash. On 11/26/12 at 12:53 p.m, while 2 CNA's performed incontinent care; an observation was made of brown soft stool in Resident #132's brief. On 11/26/12 at 12:56 p.m. an interview was conducted with S15LPN. She said that she was not aware that Resident #132 was having 3 and 4 foul loose stools a day because she had been on vacation and the CNA staff had not informed her. On 11/26/2012 at 1:04 p.m., an interview was conducted with S17CNA. She stated she cleaned the shower after she bathed Resident #132 with Potencia U-4. Review of Potencia U4's chemical makeup as S17CNA read it out loud revealed the following: Agua 2-[MEDICATION NAME] Potacio Hidroxido Alto Jabon de Aceite Potasio Tetradosodium [MEDICATION NAME] Fragancia Tenido S17CNA stated she got the cleaning agent that she cleaned the shower with from the housekeeping department already mixed. She said she sprayed it on the shower chair, let it sit for 10 minutes and rinsed it off. She said after she bathed Resident #132, she bathed Resident #32, #68 and #140. On 11/26/12 at 1:41 p.m., an interview was conducted with S18Housekeeping Aide. She stated she got the cleaning agent; Potencia U4, out the utility room. She said she put a little water in the bottle and mixed it and gave it to the CNAs to clean with. On 11/26/12 at 1:51 p.m., an interview was conducted with S19Housekeeping Supervisor. She said that Potencia U4 was a Degreaser. She said it was already premixed when the CNAs received it from them. She stated the housekeeping department was responsible for mixing it and giving it to the CNAs. She said the Potencia U4 was not mixed very often. She said it might be a week or so before the CNAs ran out of the cleaning agent before she mixed anymore. She said the bottle of Potencia U4 S17CNA used to clean the shower after Resident #132 had not been mixed recently. She confirmed the bottle that the Potencia U4 was in, did not give any instructions on how long to leave it on for cleaning but there were instructions on the shower in the community bathroom to leave the cleaning agent on for 10 minutes. On 11/26/12 at 2:01 p.m., an interview was conducted with S7InfectionControlNurse. She stated that once the facility found a resident was on contact isolation, the protocol was to institute contact precautions that day but confirmed the facility obtained a positive lab result for[DIAGNOSES REDACTED] for Resident #132 on 11/5/12; [MEDICATION NAME] 500 mg for 11/6/12 and an order for [REDACTED]. On 11/26/12 at 2:19 p.m. an interview was conducted with S9ADON. She stated that they have a shower log that CNA's maintain to inform the staff who was bathed. Review of the Shower Log for the hall Resident #132 resided on revealed the resident had a shower on 11/26/12 given by S17CNA. On 11/26/12 2:28 p.m. an interview was conducted with S15LPN. She confirmed the facility received lab results on 11/5/12 confirming that Resident #132 was positive for[DIAGNOSES REDACTED] and an order was not obtained until 11/9/12 to place the resident on contact isolation. On 11/26/12 at 2:30 p.m., an observation was made of Resident #132's son leaning over her bed without protective equipment; folding her covers back, and touching her. Further observation noted that the resident's son walked out of the resident's room without washing his hands.. On 11/26/12 at 2:25 p.m., an interview was conducted with S15LPN. She said the resident's son was aware the resident had[DIAGNOSES REDACTED], but that she had not educated him on the importance of wearing protective equipment and handwashing while the resident as on contact isolation and she would talk to him on that day. On 11/26/12 at 3:15 p.m. an interview was conducted with S19Housekeeping Supervisor. She stated the housecleaning department cleaned all the rooms with U1, U4 and CM; but confirmed none of them killed[DIAGNOSES REDACTED]. Review of the literature on the above noted chemicals revealed the following: U4-'This product is truly the most versatile cleaner in anyone's line. A water-based cleaner and degreaser, formulated to remove grease, oil, carbon or any other industrial soil from concrete, machinery, engines, floors, walls, etc. Low foaming for use in automatic scrubbers...(chemical makeup as noted above) U1/CM-germicidal. No information given per staff as to what either of these chemicals killed. On 11/26/12 at 4:15 p.m., an interview was conducted via phone with S17CNA. She stated she had been giving residents showers around July or August 2012 and she had been using the Potencia U4(degreaser) since then. She stated that whenever the cleaning solution was low, she asked the housekeeping supervisor to refill it. On 11/26/12 at 4:20 p.m., an interview was conducted with S7InfectionControlNurse. She verified that S17CNA had been working in the shower since May 11, 2012. She stated the shower aides were in-serviced on 1/26/11 on how to clean the shower room/shower chair for a resident who had scabies, but there was no documented evidence of an in-service for a resident with[DIAGNOSES REDACTED]. She said they were informed to use U1 plus a germicidal cleaner before and after that resident. She acknowledged that the facility had no documented evidence that the current shower aides had been in-serviced on what to clean the shower with for a resident with[DIAGNOSES REDACTED]. She said that she did not know who told S17CNA to clean the shower/shower chair with U4 and that she was supposed to be cleaning it with U1. She acknowledged U1 did not kill[DIAGNOSES REDACTED]. She stated that the shower aides received the cleaning supplies for the shower from the housekeeping department, but made no mention of who monitored the shower aides when cleaning the shower or what cleaning agents used. On 11/27/12 11:47 a.m., an observation was made of S18Housekeeping Aide standing in Resident #132's doorway putting on a disposable gown and a hat retrieved from the isolation cart near Resident #132's room. On 11/27/12 at 11:48 a.m., an interview was conducted with S18HousekeepingAide. She stated, "I'm about to clean Resident #132's room with Fresh Breeze TB, I guess". She said she was waiting on her supervisor to come tell her what to clean the resident's room with. On 11/28/12 at 7:37 a.m.,. an observation was made of S8LPN entering Resident #132's room without a gown, mask and foot covers. S8LPN was observed touching the resident covers and upper extremities. Further observation noted that the resident's family member was touching and leaning over the resident without a gown, gloves, mask or shoe covers. The family member then retrieved a cell phone out of his pocket and placed in up to his ear and exited the room, without washing his hands. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. On 11/28/12 at 7:39 a.m. an interview was conducted with S8LPN. She stated that she was the staff nurse taking care of Resident #132 and did not know the resident was still on contact isolation. She said that resident's family member told her that she still had[DIAGNOSES REDACTED] and confirmed she did not wear the gown, mask, foot covers or gloves while touching the resident, nor did she wash her hands when she came out of the resident's room. On 11/28/12 at 7:40 a.m. an observation was made of S20LPN entering into Resident #132's room without a gown, mask, gloves and shoe covers conversing with the resident's family member. On 11/28/2012 at 7:43 a.m. an interview was conducted with S20LPN. She stated that she did not know Resident #132 was on contact isolation and confirmed she did not put a gown, gloves and shoe covers before entering the resident's room and was supposed to. On 11/28/12 at 3:12 p.m., an interview was conducted with S2DON. She confirmed the facility staff was not implementing contact isolation precautions on 11/26/12 because S15LPN told the CNAs that Resident #132 was no longer on contact isolation before obtaining a discontinue order. She said the facility staff/family were supposed to be putting on a disposable gown, gloves, mask and shoe covers before entering the resident's room on contact isolation and removing the protective equipment before exiting. She acknowledged the staff/family members were supposed to wash their hands before and after providing care for to the resident. She confirmed S17CNA gave Resident #132 who had[DIAGNOSES REDACTED]; a shower and used Potencia U4(degreaser) to clean the shower; but was supposed to be using U1 which was a germicidal agent. She said the Potencia U4 was not a germicidal agent; it was a cleaner/degreaser. She stated U1 was the actual germicidal agent the CNAs were supposed to be using for cleaning the showers; but verified it does not kill[DIAGNOSES REDACTED]. S2DON acknowledged 3 other residents(#32, #68, #140) were showered after Resident #132 without the shower being disinfected properly with an agent that killed[DIAGNOSES REDACTED] and should not have been.

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well being for 3 (#32, #68, #140) of 4(#32, #68, #140, #132) sampled residents reviewed for Infection Control that were showered in a community bathroom after resident(#132) who was on Contact Isolation for [MEDICAL CONDITION](C Diff). The facility further failed to be administered in a manner to ensure that the 41 residents on Hall A (#4, #5, #8, #12, #13, #15, #19, #26, #29, #32, #38, #42, #46, #51, #54, #55, #59, #63, #64, #68, #72, #74, #83, #88, #89, #92, #102, #104, #106, #108, #109, #110, #123, #128, #134, #140, #147, #153, #154, #157, #160) from a total census of 121 residents were not subjected to staff who did not follow proper isolation precautions, before entering their rooms, after leaving a Resident #132's room with a known infectious organism. The Administrative staff failed to: 1) Have a system in place to ensure CNA's disinfect the shower chair/shower room according to Centers for Disease Control(CDC) Standards after showering a resident (#132) who was in Contact Isolation due to [MEDICAL CONDITION](C Diff). 2) Have a system in place to ensure the CNA's were monitored for using the proper disinfective agent after a resident(#132) diagnosed with [REDACTED]. 3) Ensure staff performed proper handwashing techniques before, during and after performing care for a resident on Contact Isolation (#132). 4) Ensure staff/family follow facility polices and procedures for Contact Isolation Precautions. 5) Ensure staff did not transport clean linen out a resident's( room on [MEDICAL CONDITION] (#132) and take it to another resident's room for usage. 6) Continue Contact Isolation precautions for a resident (#132) diagnosed with [REDACTED]. 7) Prevent the possible transmission of [MEDICAL CONDITION] to 3(#32, #68, #140) other residents in the facility when a resident(#132)diagnosed with [REDACTED]. Resident #32, #68 and #140 were placed in Immediate Jeopardy on 11/26/12 when S17CNA showered the residents in a shower room/chair without disinfecting them according to CDC guidelines after they were used by Resident #132. Resident #132 had orders for Contact Isolation related to a [DIAGNOSES REDACTED]. The Administrator was notified of the Immediate Jeopardy on 11/26/12 at 5:28 p.m. A Plan of Removal was presented by the Administrator which read: ...This morning after this was identified, the nursing staff was inserviced on [MEDICAL CONDITION] and Isolation, including obtaining orders for isolation to begin and not discontinuing until ordered by the Medical Doctor(MD). All shifts will be inserviced today. ...The Housekeeping Department Head inserviced the housekeeping staff today as well regarding communication with staff when a resident is in isolation to ensure that supplies are gathered for [MEDICAL CONDITION] cleaning procedure(2 biohazardous bags, including 2 trash liners, 1 bottle of Clorox germicidal bleach mixture, 1 fresh mop head, 1 fresh ...... mop). To dress in proper Personal Protective Equipment(PPE) before entering the [MEDICAL CONDITION] room(Put on isolation gown, shoe covers, hair cap, face mask, disposable gloves). Collect trash and soiled linen(collect all personal items and place in a double lined trash bag, collect all trash in room and place in double lined trash bag, place all soiled linen in a trash liner that is then placed inside a yellow biohazard bag). Clean and disinfect [MEDICAL CONDITION] room with bleach spray, clean and disinfect bathroom with bleach spray, mop the entire room with disinfectant with bleach, dispose of mop head in double lined bag for disposal. Exit clean room and discard all PPE(see attached). The shower room was cleaned by housekeeping with Clorox cleanup cleaner with bleach spray formula for 10 minutes of exposure time. The housekeeping manager cleaned the shower room again with the Bleach mixture of 8 parts water and 1 part bleach for a minimum of 10 minutes exposure time. The resident's room was cleaned with the Bleach disinfecting wipes. The shower aides will use Bleach spray which consists of 8 parts water with 1 part bleach, this is a 9:1 solution, for at least 10 minutes of exposure time after showering each resident and all shower aides will be inserviced regarding using the Clorox germicidal bleach mixture and that it must be discarded after 24 hours. For the 3 resident's placed in Jeopardy: The MD was notified of the potential exposure. Orders were received to monitor these residents for symptoms including watery stools, fever, loss of appetite, nausea. stomach pains. ... The family members were notified of the potential exposure. For any other resident with [MEDICAL CONDITION]: Nursing and CNA staff were inserviced regarding[DIAGNOSES REDACTED], isolation precautions, potential for spread of infection and observing isolation until the MD discontinues. Also housekeeping staff have been inserviced for proper cleaning of the rooms and observing isolation policies. The bleach solution will be used for the cleaning of the rooms for resident's with[DIAGNOSES REDACTED] and cleaning of the showers between each resident. Shower aides were inserviced regarding using bleach solution which consists of 8 parts water with 1 part bleach this is a 9:1 solution and will be prepared by the housekeeping supervisor or designee each morning. They were also inserviced that the solution expires after 24 hours via the phone on 11/27/12 by DON and ADON. The housekeeping supervisor and housekeeping staff will be inserviced on the Clorox germicidal bleach mixture. The housekeeping supervisor and housekeeping staff will be inserviced that the Clorox germicidal bleach mixture should be mixed daily using 1 part bleach to 8 parts of water to achieve a 1:9 solution. Housekeeping staff will complete inservices by Wednesday, November 28. The nursing staff and housekeeping staff will complete inservices by December 1, 2012 for the following: the Bleach Mixture is only good for 24 hours and should be disposed of after 24 hours. The spray bottles will be replenished with a new batch of solution with 1 part bleach and 8 parts water and will be labeled with the date and time each morning. Use of bleach spray in the shower between showering each resident. The Immediate Jeopardy was removed on 11/27/12 at 4:15 p.m. when the surveyors confirmed that the facility's plan of removal to clean and disinfect the shower chair/room was implemented. The deficient practice remains at a level 2 for a potential for more than minimal harm for any resident that can potentially become infected with [MEDICAL CONDITION]. The A hall residents (#4, #5, #8, #12, #13, #15, #19, #26, #29, #32, #38, #42, #46, #51, #54, #55, #59, #63, #64, #68, #72, #74, #83, #88, #89, #92, #102, #104, #106, #108, #109, #110, #123, #128, #134, #140, #147, #153, #154, #157, #160) were placed in Immediate Jeopardy on 11/28/12 at 7:37 a.m., when S8LPN entered Resident #132's room who had [MEDICAL CONDITION] without a gown, mask and foot covers. S8LPN was observed touching the resident covers and upper extremities. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. The Administrator was notified of the Immediate Jeopardy on12/12/12 at 12:05 p.m. A plan of removal was presented by the Administrator which read: 1. How corrective actions were accomplished for those residents found to have been affected by the stated deficient practice: ?The LPN involved has been inserviced and counseled regarding the break in policy for isolation residents. ?The resident is currently hospitalized for [REDACTED]. 2. Any resident with [MEDICAL CONDITION] has the potential to be affected by the stated deficient practice: ?There are no other residents in the facility with D-Diff. ?There are not residents in the facility who require isolation. 3. Measures put in place that will be made to ensure that the stated deficient practice will not recur: ?Staff have been inservice for Isolation Policies and Proper Handwashing. ?Hand Sanitizer is on all med carts and in the common areas. ?Nursing Administration will identify any resident who has [MEDICAL CONDITION] and review Isolation and Handwashing policies with staff at that time. ?Infection Control nurse will check Isolation cart and educate staff in the event that resident is positive for [MEDICAL CONDITION]. 4. How the facility plans to monitor its performance to make sure that solutions are sustained: ?Any resident who is positive for [MEDICAL CONDITION] will be identified by Nursing Administration. ?Staff will be re-educated regarding Isolation and Handwashing in the event a resident is identified as having [MEDICAL CONDITION]. ?The DON or designee will monitor staff practice for Isolation and Handwashing on a regular basis. ?Any staff member who fails to follow Isolation and Handwashing guidelines will be counseled and re-educated. Continued breaks in compliance will result in disciplinary action. 5. Corrective Action is completed as of 12/12/12. Inservices were stared on 12/10/12 and have been completed. The Immediate jeopardy was removed on 12/04/12 at 09:15 a.m. when the resident was admitted to a local hospital. The deficient practice remains at a level 2 for a potential for more than minimal harm for residents on the A hall. Findings: Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1.. 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6.. Review of the three facility's policies received revealed the following in part: a. Infection Control Policy Title: [MEDICAL CONDITIONS] Policy: dated 04/01/07 The facility is committed to providing a safe and healthy environment for resident's and to minimize or prevent the spread of infections. Purpose To prevent transmission of [MEDICAL CONDITION] to other residents. Procedure: 1.Prevention of [MEDICAL CONDITION]: 1.1 Wash resident ' s hands 1.1.1 When soiled with feces; 1.1.2 After they handle items which may be contaminated (e.g., commode) 1.2. Employees wash their hands: 1.2.1 After incontinence care; 1.2.2 After helping toilet a resident; 1.2.3 After handling potentially contaminated items; 1.2.8 After removal of personal protective clothing. 1.6 Disinfect shower area... 2. Interventions: 2.3 Use standard precautions except for residents with diarrhea associated with [MEDICAL CONDITION]. In this case, use contact precautions. b. [MEDICAL CONDITION] Policy (Revised date: April 2010) Policy Statement Preventive measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with ,[MEDICAL CONDITION]. Dificile (to prevent transmission of ,[MEDICAL CONDITION]. Dificile to others). Policy Interpretation and Implementation 6. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant handwashing with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of [MEDICAL CONDITION] spores from hands. 7. Due to the persistence of [MEDICAL CONDITION] spores for prolonged periods of time, all fecally-contaminated articles must be considered potentially infectious and disinfected with a disinfecting agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution... 9. Steps toward prevention and early intervention include: ...c. Hand washing of staff and residents... f. Disinfection of items with fecal soiling (e.g., bedpans, commode chairs, bedrails, etc.) using a disinfectant agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution)... c. Isolation Policy (Revised October 2010) Policy Statement Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions or Airborne Precautions... Policy Interpretation and Implementation ...4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Control Coordinator discontinues them, which should occur after pertinent criteria for discontinuation are met... 5. When Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room... c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room... On 11/26/12 at 8:15 a.m. an observation was noted of a 3 compartment plastic storage device sitting in hallway with gowns, gloves and protection plus briefs near Resident #132's room. Further observation was made of Resident #132 lying in the bed in her room with the door open. No sign was noted alerting staff/family to see the nurse. On 11/26/12 at 8:19 a.m. interview was conducted with S15LPN. She verified Resident #132 was on Contact Isolation Precautions. She said she told the CNAs to take the Contact Isolation precautions sign down; because the resident had finished taking her antibiotics. She stated she told the CNAs she would get an order to discontinue isolation precautions on that day. She said that "Right now, technically, the resident was still on Contact Isolations, but that it was on her To do list to get an order to discontinue it". She said the CNAs took the sign down this morning for Contact Isolation but confirmed there was no order to do so. She stated she had been on vacation so she didn't really know if the physician wanted the resident to remain on Contact Isolation Precautions. Review of Resident #132's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent Minimum Data Set(MDS) with an Assessment Review Date of 10/27/12 revealed the resident ' s Brief Interview for Mental Status(BIMS) Total Summary Score in Section C-Cognitive Pattern C0500 to be a 10; Moderately Impaired. Review of the Resident #132's Physician order [REDACTED]. 11/5/12 1:30 p.m. Stool x 1 for [MEDICAL CONDITION](Diff) 11/6/12 at 12:00 noon [MEDICATION NAME] 500 milligrams(mg) per peg every(q) 6 hours times 2 weeks for [MEDICAL CONDITION]. 11/9/12 Contact Isolation for [MEDICAL CONDITION]. Review of Resident #132's Laboratory Report dated 11/5/12 revealed the resident was positive for [MEDICAL CONDITION]. Review of Resident 132's Comprehensive Plan of Care for Infection revealed the following in part: Problem, Need, Strength, Potential Concern: Stool As evidenced by: Abnormal Labs Related to Resident diagnosed of: [MEDICAL CONDITION] Goal: Resident will have no signs or symptoms of active infection as evidenced by: [MEDICAL CONDITION] stool culture Resident will maintain adequate hydration as evidenced by moist mucous membranes, supple skin turgor, stable lab values as prescribed until resolution of infectious process. Approaches: ...Post antibiotic therapy lab work as ordered and report results to physician... Encourage good clean hygiene techniques to avoid cross-contamination, especially hand washing before meals and after bowel movements... On 11/26/12 at 10:27 a.m., an interview was conducted with S16CNA. She stated Resident #132 had been having loose, foul smelling stools 3 and 4 times a day since they put her on Contact Isolation and it never got better. She said that she asked S15LPN was the resident still on Contact Isolation when she came to work this morning because they had been wearing gowns, gloves and a mask. S15LPN told her Resident #132 finished her antibiotics and to take the Contact Isolation sign down. She said she removed the sign and the Biohazard Carts but left the 3 compartment cart outside the door. She said that she only wore gloves when she went in the resident' s room this morning and that she had not worn a gown, mask or shoe covers. On 11/26/12 at 10:29 a.m. an interview was conducted with S15LPN. She stated that she called Resident #132's physician and obtained an order for [REDACTED]. On 11/26/12 at 10:30 a.m. an observation noted the staff going in and out of the resident's room with the door left open without protective equipment. Review of Resident #132's clinical record revealed an order on 11/26/12 at 9:00 a.m. for Stool x 1. Continue Contact Isolation until [MEDICAL CONDITION] is resolved. On 11/26/12 at 10:54 a.m., an observation was made of S16CNA entering Resident #132's room with a pillow case without protective equipment and exiting without washing her hands. On 11/26/12 at 11:04 am. an observation was made of a S17CNA entering Resident #132's room without protective equipment on with 2 clear bags of clean linen. Further observation noted S17CNA exiting the resident's room, without washing her hands, with 1 bag of clean linen and entering another resident's room. On 11/26/12 at 11:07 a.m. an interview was conducted with S17CNA. She said that S15LPN informed her Resident #132 was not on Contact Isolation. She confirmed she had 2 clear bags of clean linen with her when she entered Resident #132's room. She said she left 1 bag in Resident #132's room and she took the other clear bag of linen from Resident #132's room to another resident's room. She confirmed that she was not supposed to take clean linen out of Resident #132's room; who was on Contact Isolation, to another resident's room. She also said she put a gown on Resident #132 and transported her to the community bathroom and gave her a shower. She said that after the resident's bath, she took the resident's gown back down the hall to her room without it being in a double lined trash bag and put it in her hamper for her family to wash. On 11/26/12 at 12:53 p.m, while 2 CNAs performed incontinent care; an observation was made of brown soft stool in Resident #132's brief. On 11/26/12 at 12:56 p.m. an interview was conducted with S15LPN. She said that she was not aware that Resident #132 was having 3 and 4 foul loose stools a day because she had been on vacation and the CNA staff had not informed her. On 11/26/2012 at 1:04 p.m., an interview was conducted with S17CNA. She stated she cleaned the shower after she bathed Resident #132 with Potencia U-4. Review of Potencia U4's chemical makeup as S17CNA read it out loud revealed the following: Agua 2-[MEDICATION NAME] Potacio Hidroxido Alto Jabon de Aceite Potasio Tetradosodium [MEDICATION NAME] Fragancia Tenido S17CNA stated she got the cleaning agent that she cleaned the shower with from the housekeeping department already mixed. She said she sprayed it on the shower chair, let it sit for 10 minutes and rinsed it off. She said after she bathed Resident #132, she bathed Resident #32, #68 and #140. On 11/26/12 at 1:41 p.m., an interview was conducted with S18Housekeeping Aide. She stated she got the chemical Potencia U4 out the utility room. She said she put a little water in the bottle and mixed it and gave it to the CNAs to clean with. On 11/26/12 at 1:51 p.m., an interview was conducted with S19Housekeeping Supervisor. She said that Potencia U4 was a Degreaser. She said it was already premixed when the CNAs received it from them. She stated the housekeeping department was responsible for mixing it and giving it to the CNAs. She said the Potencia U4 was not mixed very often. She said it might be a week or so before the CNAs ran out of the cleaning agent before she mixed anymore . She said the bottle of Potencia U4 S17CNA used to clean the shower after Resident #132 had not been mixed recently. She acknowledged the bottle that the Potencia U4 was in, did not give any instructions on how long to leave it on for cleaning but there were instructions on the shower in the community bathroom to leave the cleaning agent on for 10 minutes. On 11/26/12 at 2:01 p.m., an interview was conducted with S7Infection Control Nurse. She stated that once the facility found a resident was on Contact Isolation, the protocol was to institute Contact Precautions that day; but confirmed the facility obtained a positive lab result for [MEDICAL CONDITION] for Resident #132 on 11/5/12; [MEDICATION NAME] 500 mg for 11/6/12 and an order for [REDACTED]. On 11/26/12 at 2:19 p.m. an interview was conducted with S9ADON. She stated that they have a shower log that CNA's maintain to inform the staff who was bathed. Review of the Shower Log for the hall Resident #132 resided on revealed the resident had a shower on 11/26/12 given by S17CNA. On 11/26/12 2:28 p.m. an interview was conducted with S15LPN. She confirmed the facility received lab results on 11/5/12 confirming that Resident #132 was positive for [MEDICAL CONDITION] and an order was not obtained until 11/9/12 to place the resident on Contact Isolation. On 11/26/12 at 2:30 p.m,. an observation was made of Resident #132's son leaning over her bed without protective equipment; folding her covers back, touching her. Further observation noted that the resident's son walked out of the resident's room; without washing his hands.. On 11/26/12 at 2:25 p.m., an interview was conducted with S15LPN. She said the resident's son was aware the resident had [MEDICAL CONDITION], but that she had not educated him on the importance of wearing protective equipment and handwashing while the resident was on Contact Isolation and she would talk to him on that day. On 11/26/12 at 3:15 p.m. an interview was conducted with S19Housekeeping Supervisor. She stated the housecleaning staff cleaned all the rooms with U1, U4 and CM but confirmed none of them killed [MEDICAL CONDITION]. Review of the literature on the above noted chemicals revealed the following: U4-'This product is truly the most versatile cleaner in anyone's line. A water-based cleaner and degreaser, formulated to remove grease, oil, carbon or any other industrial soil from concrete, machinery, engines, floors, walls, etc. Low foaming for use in automatic scrubbers...(chemical makeup as noted above) U1/CM-germicidals No information given per staff as to what either of these chemicals killed. On 11/26/12 at 4:15 p.m., an interview was conducted via phone with S17CNA. She stated she had been giving resident's showers around July or August 2012 and she had been using the Potencia U4(degreaser) since then. She said that she was inserviced to leave the cleaning agent on for 10 minutes after applying it, but can't recall a specific cleaning agent she was inserviced on. She said whenever she cleaning solution got low, she asked the housekeeping supervisor for a refill and she used whatever they gave her. On 11/26/12 at 4:20 p.m., an interview was conducted with S7Infection Control Nurse. She verified that S17CNA had been working in the shower since May 11, 2012. She stated the shower aides were inserviced on 1/26/11 on how to clean the shower room/shower chair for a resident who had scabies, but there was no documented evidence of an inservice for a resident with [MEDICAL CONDITION]. She said they were informed to use U1 plus a Germicidal cleaner before and after that resident. She acknowledged that the facility had no documented evidence that the current shower aides had been inserviced on what to clean the shower with for a resident with [MEDICAL CONDITION]. She said that she did not know who told S17CNA to clean the shower/shower chair with U4 and that she was supposed to be cleaning it with U1. She acknowledged U1 did not kill [MEDICAL CONDITION]. She stated that the shower aides received the cleaning supplies for the shower from the housekeeping department but made no mention of who monitored the shower aides when cleaning the shower or what cleaning agents used. On 11/27/12 11:47 a.m., an observation was made of S18Housekeeping Aide standing in Resident #132's doorway putting on a disposable gown and a hat retrieved from the Isolation Cart near Resident #132's room. On 11/27/12 at 11:48 a.m., an interview was conducted with S18Housekeeping Aide. She stated, "I'm about to clean Resident #132's room with Fresh Breeze TB, I guess". She said she was waiting on her supervisor to come tell her what to clean the resident's room with. On 11/28/12 at 7:37 a.m.,. an observation was made of S8LPN entering Resident #132's room without a gown, mask and shoe covers. S8LPN was observed touching the resident covers and upper extremities. Further observation noted that the resident's family member was touching and leaning over the resident without a gown, gloves, mask or shoe covers. The family member then retrieved a cell phone out of his pocket and placed in up to his ear and exited the room, without washing his hands. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. On 11/28/12 at 7:39 a.m. an interview was conducted with S8LPN. She stated that she was the staff nurse taking care of Resident #132 and did not know the resident was still on Contact Isolation. She said that resident's family member told her that she still had [MEDICAL CONDITION] and confirmed she did not wear the gown, mask, shoe covers or gloves while touching the resident, nor did she wash her hands when she came out of the resident's room. On 11/28/12 at 7:40 a.m. an observation was made of S20LPN entering into Resident #132's room without a gown, mask, gloves and shoe covers conversing with the resident's family member. On 11/28/2012 at 7:43 a.m. an interview was conducted with S20LPN. She stated that she did not know Resident #132 was on Contact Isolation and confirmed she did not put a gown, foot covers, gloves and shoe covers before entering the resident's room and was supposed to. On 11/28/12 at 3:12 p.m., an interview was conducted with S2DON. She confirmed the facility staff was not implementing Contact Isolation Precautions for Resident #132 on 11/26/12; because S15LPN told the CNAs, Resident #132 was no longer on Contact Isolation before obtaining a discontinue order. She confirmed S17CNA gave Resident #132 who had [MEDICAL CONDITION]; a shower and used Potencia U4(degreaser) to clean the shower; but was supposed to be using U1 which was a germicidal agent. She said the Potencia U4 was not a germicidal agent; it was a cleaner/degreaser. She stated U1 was the actual germicidal agent the CNAs were supposed to be using for cleaning the showers but that it did not kill [MEDICAL CONDITION]. She stated the S7Infection Control Nurse was responsible for inservicing the staff on following policies and procedures for wearing protective equipment before entering the resident's room on Contact Isolation and removing the protective equipment before exiting. She said that S7Infection Control Nurse was also responsible for ensuring the current shower aide were inserviced on properly disinfecting the community shower for a resident with [MEDICAL CONDITION], the importance of handwashing before and after providing care for a resident on Contact Isolation and transporting linens for a person on Contact Isolation. She acknowledged there was no system in place to monitor the shower aides to ensure they were using the proper cleaning agent to disinfect the community shower for a resident on [MEDICAL CONDITION].

Based on observations, record reviews and interviews, the facility failed to ensure CNAs(Certified Nursing Assitant) carried out appropriate infection control precautions. The facility failed to: 1) Disinfect the shower chair/shower room according to Centers for Disease Control(CDC) Standards after showering a resident (#132) who was in Contact Isolation due to [MEDICAL CONDITION](C Diff). 2) Ensure staff used proper handwashing techniques before, during and after performing care for a resident on Contact Isolation. (#132) 3) Ensure staff wore proper protective clothing before entering a room for a resident who was on Contact Isolation. (#132) 4) Ensure staff was inserviced on the proper cleaning agent required to disinfect the community shower after a resident with [MEDICAL CONDITION]. (#132) 5) Ensure staff did not transport clean linen out a resident's room on [MEDICAL CONDITION] (#132) and take it to another resident's room for usage. Resident #32, #68 and #140 were placed in Immediate Jeopardy on 11/26/12 when S17CNA showered the residents in a shower room/chair without disinfecting them according to CDC guidelines after they were used by Resident #132. Resident #132 had orders for Contact Isolation related to a [DIAGNOSES REDACTED]. The Administrator was notified of the Immediate Jeopardy on 11/26/12 at 5:28 p.m. A Plan of Removal was presented by the Administrator which read: ...This morning after this was identified, the nursing staff was inserviced on [MEDICAL CONDITION] and Isolation, including obtaining orders for isolation to begin and not discontinuing until ordered by the Medical Doctor(MD). All shifts will be inserviced today. ...The Housekeeping Department Head inserviced the housekeeping staff today as well regarding communication with staff when a resident is in isolation to ensure that supplies are gathered for [MEDICAL CONDITION] cleaning procedure(2 biohazardous bags, including 2 trash liners, 1 bottle of Clorox germicidal bleach mixture, 1 fresh mop head, 1 fresh ...... mop). To dress in proper Personal Protective Equipment(PPE) before entering the [MEDICAL CONDITION] room(Put on isolation gown, shoe covers, hair cap, face mask, disposable gloves). Collect trash and soiled linen(collect all personal items and place in a double lined trash bag, collect all trash in room and place in double lined trash bag, place all soiled linen in a trash liner that is then placed inside a yellow biohazard bag). Clean and disinfect [MEDICAL CONDITION] room with bleach spray, clean and disinfect bathroom with bleach spray, mop the entire room with disinfectant with bleach, dispose of mop head in double lined bag for disposal. Exit clean room and discard all PPE(see attached). The shower room was cleaned by housekeeping with Clorox cleanup cleaner with bleach spray formula for 10 minutes of exposure time. The housekeeping manager cleaned the shower room again with the Bleach mixture of 8 parts water and 1 part bleach for a minimum of 10 minutes exposure time. The resident's room was cleaned with the Bleach disinfecting wipes. The shower aides will use Bleach spray which consists of 8 parts water with 1 part bleach, this is a 9:1 solution, for at least 10 minutes of exposure time after showering each resident and all shower aides will be inserviced regarding using the Clorox germicidal bleach mixture and that it must be discarded after 24 hours. For the 3 resident's placed in Jeopardy: The MD was notified of the potential exposure. Orders were received to monitor these residents for symptoms including watery stools, fever, loss of appetite, nausea. stomach pains. ... The family members were notified of the potential exposure. For any other resident with [MEDICAL CONDITION]: Nursing and CNA staff were inserviced regarding[DIAGNOSES REDACTED], isolation precautions, potential for spread of infection and observing isolation until the MD discontinues. Also housekeeping staff have been inserviced for proper cleaning of the rooms and observing isolation policies. The bleach solution will be used for the cleaning of the rooms for resident's with[DIAGNOSES REDACTED] and cleaning of the showers between each resident. Shower aides were inserviced regarding using bleach solution which consists of 8 parts water with 1 part bleach this is a 9:1 solution and will be prepared by the housekeeping supervisor or designee each morning. They were also inserviced that the solution expires after 24 hours via the phone on 11/27/12 by DON and ADON. The housekeeping supervisor and housekeeping staff will be inserviced on the Clorox germicidal bleach mixture. The housekeeping supervisor and housekeeping staff will be inserviced that the Clorox germicidal bleach mixture should be mixed daily using 1 part bleach to 8 parts of water to achieve a 1:9 solution. Housekeeping staff will complete inservices by Wednesday, November 28. The nursing staff and housekeeping staff will complete inservices by December 1, 2012 for the following: the Bleach Mixture is only good for 24 hours and should be disposed of after 24 hours. The spray bottles will be replenished with a new batch of solution with 1 part bleach and 8 parts water and will be labeled with the date and time each morning. Use of bleach spray in the shower between showering each resident. The Immediate Jeopardy was removed on 11/27/12 at 4:15 p.m. when the surveyors confirmed that the facility's plan of removal to clean and disinfect the shower chair/room was implemented. The deficient practice remains at a level 2 for a potential for more than minimal harm for any resident that can potentially become infected with [MEDICAL CONDITION]. Findings: Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1 ... 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6 ... Review of the three facility's policies received revealed the following in part: a. Infection Control Policy Title: [MEDICAL CONDITIONS] Policy: dated 04/01/07 The facility is committed to providing a safe and healthy environment for resident's and to minimize or prevent the spread of infections. Purpose To prevent transmission of [MEDICAL CONDITION] to other residents. Procedure: 1.Prevention of [MEDICAL CONDITION]: 1.1 Wash resident ' s hands 1.1.1 When soiled with feces; 1.1.2 After they handle items which may be contaminated (e.g., commode) 1.2. Employees wash their hands: 1.2.1 After incontinence care; 1.2.2 After helping toilet a resident; 1.2.3 After handling potentially contaminated items; 1.2.8 After removal of personal protective clothing. 1.6 Disinfect shower area... 2. Interventions: 2.3 Use standard precautions except for residents with diarrhea associated with [MEDICAL CONDITION]. In this case, use contact precautions. b. [MEDICAL CONDITION] Policy (Revised date: April 2010) Policy Statement Preventive measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with ,[MEDICAL CONDITION]. Dificile (to prevent transmission of ,[MEDICAL CONDITION]. Dificile to others). Policy Interpretation and Implementation 6. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant handwashing with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of [MEDICAL CONDITION] spores from hands. 7. Due to the persistence of [MEDICAL CONDITION] spores for prolonged periods of time, all fecally-contaminated articles must be considered potentially infectious and disinfected with a disinfecting agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution... 9. Steps toward prevention and early intervention include: ...c. Hand washing of staff and residents... f. Disinfection of items with fecal soiling (e.g., bedpans, commode chairs, bedrails, etc.) using a disinfectant agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution)... c. Isolation Policy (Revised October 2010) Policy Statement Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions or Airborne Precautions... Policy Interpretation and Implementation ...4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Control Coordinator discontinues them, which should occur after pertinent criteria for discontinuation are met... 5. When Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room... c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room... On 11/26/12 at 8:15 a.m. an observation was noted of a 3 compartment plastic storage device sitting in hallway with gowns, gloves and protection plus briefs near Resident #132's room. Further observation was made of Resident #132 lying in the bed in her room with the door open. No sign was noted alerting staff/family to see the nurse. On 11/26/12 at 8:19 a.m., an interview was conducted with S15LPN. She verified Resident #132 was on Contact Isolation Precautions. She said she told the CNAs to take the Contact Isolation precautions sign down; because the resident had finished taking her antibiotics. She stated she told the CNAs she would get an order to discontinue isolation precautions on that day. She said that "Right now, technically, the resident was still on Contact Isolations but that it was on her To do list to get an order to discontinue it". She said the CNAs took the sign down this morning for Contact Isolation but confirmed there was no order to do so. She stated she had been on vacation so she didn't really know if the physician wanted the resident to remain on Contact Isolation Precautions. Review of Resident #132's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent Minimum Data Set(MDS) with an Assessment Review Date of 10/27/12 revealed the resident's Brief Interview for Mental Status(BIMS) Total Summary Score in Section C-Cognitive Pattern C0500 to be a 10; Moderately Impaired. Review of the Resident #132's Physician order [REDACTED]. 11/5/12 1:30 p.m. Stool x 1 for [MEDICAL CONDITION](Diff) 11/6/12 at 12:00 noon [MEDICATION NAME] 500 milligrams(mg) per peg every(q) 6 hours times 2 weeks for [MEDICAL CONDITION]. 11/9/12 Contact Isolation for [MEDICAL CONDITION]. Review of Resident #132's Laboratory Report dated 11/5/12 revealed the resident was positive for [MEDICAL CONDITION]. Review of Resident 132's Comprehensive Plan of Care for Infection revealed the following in part: Problem, Need, Strength, Potential Concern: Stool As evidenced by: Abnormal Labs Related to Resident diagnosed of: [MEDICAL CONDITION] Goal: Resident will have no signs or symptoms of active infection as evidenced by: [MEDICAL CONDITION] stool culture Resident will maintain adequate hydration as evidenced by moist mucous membranes, supple skin turgor, stable lab values as prescribed until resolution of infectious process. Approaches: ...Post antibiotic therapy lab work as ordered and report results to physician... Encourage good clean hygiene techniques to avoid cross-contamination, especially hand washing before meals and after bowel movements... On 11/26/12 at 10:27 a.m., an interview was conducted with S16CNA. She stated Resident #132 had been having loose, foul smelling stools 3 and 4 times a day since they put her on Contact Isolation and it never got better. She said that she asked S15LPN was the resident still on Contact Isolation when she came to work this morning because they had been wearing gowns, gloves and a mask. S15LPN told her Resident #132 finished her antibiotics and to take the Contact Isolation sign down. She said she removed the sign and the Biohazard Carts but left the 3 compartment cart outside the door. She said that she only wore gloves when she went in the resident' s room that morning and that she had not worn a gown, mask or shoe covers. On 11/26/12 at 10:29 a.m. an interview was conducted with S15LPN. She stated that she called Resident #132's physician and obtained an order for [REDACTED]. On 11/26/12 at 10:30 a.m. an observation noted the CNA staff going in and out of the resident's room with the door left open without protective equipment. Review of Resident #132's clinical record revealed an order on 11/26/12 at 9:00 a.m. for Stool x 1. Continue Contact Isolation until [MEDICAL CONDITION] is resolved. On 11/26/12 at 10:54 a.m., an observation was made of S16CNA entering Resident #132's room with a pillow case without protective equipment on and exiting without washing her hands. On 11/26/12 at 11:04 a.m., an observation was made of a S17CNA entering Resident #132's room without protective equipment on with 2 clear bags of clean linen. Further observation noted S17CNA exiting the resident's room, without washing her hands, with 1 bag of clean linen and entering another resident's room. On 11/26/12 at 11:07 a.m., an interview was conducted with S17CNA. She said that S15LPN informed her Resident #132 was not on Contact Isolation. She confirmed she had 2 clear bags of clean linen with her when she entered Resident #132's room. She said she left 1 bag in Resident #132's room and she took the other clear bag of linen from Resident #132's room to another resident's room. She confirmed that she was not supposed to take clean linen out of Resident #132's room; who was on Contact Isolation, to another resident's room. She also said she put a gown on Resident #132 and transported her to the community bathroom and gave her a shower. She said that after the resident's bath, she took the resident's gown back down the hall to her room without it being in a double lined trash bag and put it in her hamper for her family to wash. On 11/26/2012 at 1:04 p.m., an interview was conducted with S17CNA. She stated she cleaned the shower after she bathed Resident #132 with Potencia U-4. Review of Potencia U4's chemical makeup as S17CNA read it out loud revealed the following: Agua 2-[MEDICATION NAME] Potacio Hidroxido Alto Jabon de Aceite Potasio Tetradosodium [MEDICATION NAME] Fragancia Tenido S17CNA stated she got the cleaning agent that she cleaned the shower with from the housekeeping department already mixed. She said she sprayed it on the shower chair, let it sit for 10 minutes and rinsed it off. She said after she bathed Resident #132, she bathed Resident #32, #68 and #140. On 11/26/12 at 1:41 p.m., an interview was conducted with S18Housekeeping Aide. She stated she got the chemical Potencia U4 out the utility room. She said she put a little water in the bottle and mixed it and gave it to the CNAs to clean with. On 11/26/12 at 1:51 p.m., an interview was conducted with S19Housekeeping Supervisor. She said that Potencia U4 was a Degreaser. She said it was already premixed when the CNAs received it from them. She stated the housekeeping department was responsible for mixing it and giving it to the CNAs. She said the Potencia U4 was not mixed very often. She said it might be a week or so when the CNAs run out and need to mix some more. S19Housekeeping Supervisor said the bottle of Potencia U4 that S17CNA used to clean the shower after Resident #132 had not been mixed recently. She confirmed the bottle that the Potencia U4 was in, did not give any instructions on how long to leave the cleaner on for cleaning; but there were instructions on the shower in the community bathroom to leave the cleaning agent on for 10 minutes. On 11/26/12 at 2:01 p.m., an interview was conducted with S7Infection Control Nurse. She stated that once the facility found a resident was on Contact Isolation, the protocol was to institute Contact Precautions that day; but confirmed the facility obtained a positive lab result for [MEDICAL CONDITION] for Resident #132 on 11/5/12; [MEDICATION NAME] 500 mg for 11/6/12 and an order for [REDACTED]. On 11/26/12 at 2:19 p.m., an interview was conducted with S9ADON. She stated that they have a shower log that CNAs maintain to inform the staff who was bathed. Review of the Shower Log for the hall Resident #132 resided on revealed the resident had a shower on 11/26/12 given by S17CNA. On 11/26/12 at 3:15 p.m., an interview was conducted with S19Housekeeping Supervisor. She stated the housecleaning department cleaned all the rooms with U1, U4 and CM; but confirmed none of them killed [MEDICAL CONDITION]. Review of the literature on the above noted chemicals revealed the following: U4-'This product is truly the most versatile cleaner in anyone's line. A water-based cleaner and degreaser, formulated to remove grease, oil, carbon or any other industrial soil from concrete, machinery, engines, floors, walls, etc. Low foaming for use in automatic scrubbers...(chemical makeup as noted above) U1/CM-germicidals No information given per staff as to what either of these chemicals killed. On 11/26/12 at 4:15 p.m., an interview was conducted via phone with S17CNA. She stated she had been giving resident's showers around July or August 2012 and she had been using the Potencia U4(degreaser) since then. She stated that whenever she got low in the cleaner, she asked the housekeeping supervisor for a refill. On 11/26/12 at 4:20 p.m., an interview was conducted with S7Infection Control Nurse. She verified that S17CNA had been working in the shower since May 11, 2012. She stated the shower aides were inserviced on 1/26/11 on how to clean the shower room/shower chair for a resident who had scabies but no documented evidence for a resident with [MEDICAL CONDITION]. She said the CNAs were informed to use U1 plus a Germicidal cleaner before and after that resident. She acknowledged that the facility had no documented evidence that the current shower aides had been inserviced on what to clean the shower with for a resident with [MEDICAL CONDITION]. She said that she did not know who told S17CNA to clean the shower/shower chair with U4 and that she was supposed to be cleaning it with U1. She acknowledged U1 did not kill [MEDICAL CONDITION]. She stated that the shower aides received the cleaning supplies for the shower from the housekeeping department; but made no mention of who monitored the shower aides when cleaning the shower or what cleaning agents was used. On 11/28/12 at 3:12 p.m., an interview was conducted with S2DON. She confirmed the facility staff was not implementing Contact Isolation Precautions for Resident #132 on 11/26/12; because S15LPN told the CNAs, Resident #132 was no longer on Contact Isolation before obtaining a discontinue order. She said the facility staff/family was supposed to be putting on a disposable gown, gloves, mask and shoe covers before entering the resident's room on Contact Isolation and removing the protective equipment before exiting. She acknowledged the staff/family members were supposed to wash their hands before and after providing care for to the resident. S2DON confirmed S17CNA gave Resident #132 who had [MEDICAL CONDITION]; a shower and used Potencia U4(degreaser) to clean the shower; but was supposed to be using U1 which was a germicidal agent. She said the Potencia U4 was not a germicidal agent; it was a cleaner/degreaser. She stated U1 was the actual germicidal agent the CNAs were supposed to be using for cleaning the showers; but verified it did not kill [MEDICAL CONDITION]. S2DON acknowledged 3 other residents(#32, #68, #140) were showered after Resident #132 without the shower being disinfected properly with an agent that killed [MEDICAL CONDITION] and should not have been. She stated there was no documented evidence the current shower aides were inserviced on how to properly disinfect a shower after a resident with [MEDICAL CONDITION].

Based on interviews and record reviews, the facility failed have a quality assessment and assurance committee that identified and implemented effective plans of action for quality related deficiencies (cross reference F166, F248, F325, F329, F498). The facility had a census of 121 residents. Resident #32, #68 and #140 were placed in Immediate Jeopardy on 11/26/12 when S17CNA showered the residents in a shower room/chair without disinfecting them according to CDC guidelines after they were used by Resident #132. Resident #132 had orders for Contact Isolation related to a [DIAGNOSES REDACTED]. The Administrator was notified of the Immediate Jeopardy on 11/26/12 at 5:28 p.m. A Plan of Removal was presented by the Administrator which read: ...This morning after this was identified, the nursing staff was inserviced on [MEDICAL CONDITION] and Isolation, including obtaining orders for isolation to begin and not discontinuing until ordered by the Medical Doctor(MD). All shifts will be inserviced today. ...The Housekeeping Department Head inserviced the housekeeping staff today as well regarding communication with staff when a resident is in isolation to ensure that supplies are gathered for [MEDICAL CONDITION] cleaning procedure(2 biohazardous bags, including 2 trash liners, 1 bottle of Clorox germicidal bleach mixture, 1 fresh mop head, 1 fresh ...... mop). To dress in proper Personal Protective Equipment (PPE) before entering the [MEDICAL CONDITION] room (Put on isolation gown, shoe covers, hair cap, face mask, disposable gloves). Collect trash and soiled linen(collect all personal items and place in a double lined trash bag, collect all trash in room and place in double lined trash bag, place all soiled linen in a trash liner that is then placed inside a yellow biohazard bag). Clean and disinfect [MEDICAL CONDITION] room with bleach spray, clean and disinfect bathroom with bleach spray, mop the entire room with disinfectant with bleach, dispose of mop head in double lined bag for disposal. Exit clean room and discard all PPE (see attached). The shower room was cleaned by housekeeping with Clorox cleanup cleaner with bleach spray formula for 10 minutes of exposure time. The housekeeping manager cleaned the shower room again with the Bleach mixture of 8 parts water and 1 part bleach for a minimum of 10 minutes exposure time. The resident's room was cleaned with the Bleach disinfecting wipes. The shower aides will use Bleach spray which consists of 8 parts water with 1 part bleach, this is a 9:1 solution, for at least 10 minutes of exposure time after showering each resident and all shower aides will be inserviced regarding using the Clorox germicidal bleach mixture and that it must be discarded after 24 hours. For the 3 resident's placed in Jeopardy: The MD was notified of the potential exposure. Orders were received to monitor these residents for symptoms including watery stools, fever, loss of appetite, nausea, stomach pains. ... The family members were notified of the potential exposure. For any other resident with [MEDICAL CONDITION]: Nursing and CNA staff were inserviced regarding[DIAGNOSES REDACTED], isolation precautions, potential for spread of infection and observing isolation until the MD discontinues. Also housekeeping staff have been inserviced for proper cleaning of the rooms and observing isolation policies. The bleach solution will be used for the cleaning of the rooms for residents with[DIAGNOSES REDACTED] and cleaning of the showers between each resident. Shower aides were inserviced regarding using bleach solution which consists of 8 parts water with 1 part bleach this is a 9:1 solution and will be prepared by the housekeeping supervisor or designee each morning. They were also inserviced that the solution expires after 24 hours via the phone on 11/27/12 by DON and ADON. The housekeeping supervisor and housekeeping staff will be inserviced on the Clorox germicidal bleach mixture. The housekeeping supervisor and housekeeping staff will be inserviced that the Clorox germicidal bleach mixture should be mixed daily using 1 part bleach to 8 parts of water to achieve a 1:9 solution. Housekeeping staff will complete inservices by Wednesday, November 28. The nursing staff and housekeeping staff will complete inservices by December 1, 2012 for the following: the Bleach Mixture is only good for 24 hours and should be disposed of after 24 hours. The spray bottles will be replenished with a new batch of solution with 1 part bleach and 8 parts water and will be labeled with the date and time each morning. Use of bleach spray in the shower between showering each resident. The Immediate Jeopardy was removed on 11/27/12 at 4:15 p.m. when the surveyors confirmed that the facility's plan of removal to clean and disinfect the shower chair/room was implemented. The deficient practice remains at a level 2 for a potential for more than minimal harm for any resident that can potentially become infected with [MEDICAL CONDITION]. The A hall residents (#4, #5, #8, #12, #13, #15, #19, #26, #29, #32, #38, #42, #46, #51, #54, #55, #59, #63, #64, #68, #72, #74, #83, #88, #89, #92, #102, #104, #106, #108, #109, #110, #123, #128, #134, #140, #147, #153, #154, #157, #160) were placed in Immediate Jeopardy on 11/28/12 at 7:37 a.m., when S8LPN entered Resident #132's room who had [MEDICAL CONDITION] without a gown, mask and foot covers. S8LPN was observed touching the resident covers and upper extremities. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. The Administrator was notified of the Immediate Jeopardy on12/12/12 at 12:05 p.m. A plan of removal was presented by the Administrator which read: 1. How corrective actions were accomplished for those residents found to have been affected by the stated deficient practice: ?The LPN involved has been inserviced and counseled regarding the break in policy for isolation residents. ?The resident is currently hospitalized for [REDACTED]. 2. Any resident with [MEDICAL CONDITION] has the potential to be affected by the stated deficient practice: ?There are no other residents in the facility with D-Diff. ?There are not residents in the facility who require isolation. 3. Measures put in place that will be made to ensure that the stated deficient practice will not recur: ?Staff have been inservice for Isolation Policies and Proper Handwashing. ?Hand Sanitizer is on all med carts and in the common areas. ?Nursing Administration will identify any resident who has [MEDICAL CONDITION] and review Isolation and Handwashing policies with staff at that time. ?Infection Control nurse will check Isolation cart and educate staff in the event that resident is positive for [MEDICAL CONDITION]. 4. How the facility plans to monitor its performance to make sure that solutions are sustained: ?Any resident who is positive for [MEDICAL CONDITION] will be identified by Nursing Administration. ?Staff will be re-educated regarding Isolation and Handwashing in the event a resident is identified as having [MEDICAL CONDITION]. ?The DON or designee will monitor staff practice for Isolation and Handwashing on a regular basis. ?Any staff member who fails to follow Isolation and Handwashing guidelines will be counseled and re-educated. Continued breaks in compliance will result in disciplinary action. 5. Corrective Action is completed as of 12/12/12. Inservices were stared on 12/10/12 and have been completed. The Immediate jeopardy was removed on 12/04/12 at 09:15 a.m. when the resident was admitted to a local hospital. The deficient practice remains at a level 2 for a potential for more than minimal harm for residents on the A hall. Findings: Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1.. 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6.. Review of the three facility's policies received revealed the following in part: a. Infection Control Policy Title: [MEDICAL CONDITIONS] Policy: dated 04/01/07 The facility is committed to providing a safe and healthy environment for resident's and to minimize or prevent the spread of infections. Purpose To prevent transmission of [MEDICAL CONDITION] to other residents. Procedure: 1.Prevention of [MEDICAL CONDITION]: 1.1 Wash resident ' s hands 1.1.1 When soiled with feces; 1.1.2 After they handle items which may be contaminated (e.g., commode) 1.2. Employees wash their hands: 1.2.1 After incontinence care; 1.2.2 After helping toilet a resident; 1.2.3 After handling potentially contaminated items; 1.2.8 After removal of personal protective clothing. 1.6 Disinfect shower area... 2. Interventions: 2.3 Use standard precautions except for residents with diarrhea associated with [MEDICAL CONDITION]. In this case, use contact precautions. b. [MEDICAL CONDITION] Policy (Revised date: April 2010) Policy Statement Preventive measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with ,[MEDICAL CONDITION]. Dificile (to prevent transmission of ,[MEDICAL CONDITION]. Dificile to others). Policy Interpretation and Implementation 6. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant handwashing with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of [MEDICAL CONDITION] spores from hands. 7. Due to the persistence of [MEDICAL CONDITION] spores for prolonged periods of time, all fecally-contaminated articles must be considered potentially infectious and disinfected with a disinfecting agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution... 9. Steps toward prevention and early intervention include: ...c. Hand washing of staff and residents... f. Disinfection of items with fecal soiling (e.g., bedpans, commode chairs, bedrails, etc.) using a disinfectant agent recommended for [MEDICAL CONDITION] (e.g., household bleach and water solution)... c. Isolation Policy (Revised October 2010) Policy Statement Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions or Airborne Precautions... Policy Interpretation and Implementation ...4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Control Coordinator discontinues them, which should occur after pertinent criteria for discontinuation are met... 5. When Transmission-Based Precautions are implemented, the Infection Control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room... c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room... On 11/26/12 at 8:15 a.m. an observation was noted of a 3 compartment plastic storage device sitting in hallway with gowns, gloves and protection plus briefs near Resident #132's room. Further observation was made of Resident #132 lying in the bed in her room with the door open. No sign was noted alerting staff/family to see the nurse. On 11/26/12 at 8:19 a.m. interview was conducted with S15LPN. She verified Resident #132 was on Contact Isolation Precautions. She said she told the CNA's to take the Contact Isolation precautions sign down; because the resident had finished taking her antibiotics. She stated she told the CNAs she would get an order to discontinue isolation precautions on that day. She said that "Right now, technically, the resident was still on Contact Isolations but that it was on her "To do" list to get an order to discontinue it". She said the CNAs took the sign down this morning for Contact Isolation but confirmed there was no order to do so. She stated she had been on vacation so she didn't really know if the physician wanted the resident to remain on Contact Isolation Precautions. Review of Resident #132's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent Minimum Data Set(MDS) with an Assessment Review Date of 10/27/12 revealed the resident's Brief Interview for Mental Status(BIMS) Total Summary Score in Section C-Cognitive Pattern C0500 to be a 10; Moderately Impaired. Review of the Resident #132's Physician order [REDACTED]. 11/5/12 1:30 p.m. Stool x 1 for [MEDICAL CONDITION](Diff) 11/6/12 at 12:00 noon [MEDICATION NAME] 500 milligrams(mg) per peg every(q) 6 hours times 2 weeks for [MEDICAL CONDITION]. 11/9/12 Contact Isolation for [MEDICAL CONDITION]. Review of Resident #132's Laboratory Report dated 11/5/12 revealed the resident was positive for [MEDICAL CONDITION]. Review of Resident 132's Comprehensive Plan of Care for Infection revealed the following in part: Problem, Need, Strength, Potential Concern: Stool As evidenced by: Abnormal Labs Related to Resident diagnosed of: [MEDICAL CONDITION] Goal: Resident will have no signs or symptoms of active infection as evidenced by: [MEDICAL CONDITION] stool culture Resident will maintain adequate hydration as evidenced by moist mucous membranes, supple skin turgor, stable lab values as prescribed until resolution of infectious process. Approaches: ...Post antibiotic therapy lab work as ordered and report results to physician... Encourage good clean hygiene techniques to avoid cross-contamination, especially hand washing before meals and after bowel movements... On 11/26/12 at 10:27 a.m., an interview was conducted with S16CNA. She stated Resident #132 had been having loose, foul smelling stools 3 and 4 times a day since they put her on Contact Isolation and it never got better. She said that she asked S15LPN was the resident still on Contact Isolation when she came to work this morning because they had been wearing gowns, gloves and a mask. S15LPN told her Resident #132 finished her antibiotics and to take the Contact Isolation sign down. She said she removed the sign and the Biohazard Carts but left the 3 compartment cart outside the door. She said that she only wore gloves when she went in the resident' s room this morning and that she had not worn a gown, mask or shoe covers. On 11/26/12 at 10:29 a.m., an interview was conducted with S15LPN. She stated that she called Resident #132's physician and obtained an order for [REDACTED]. On 11/26/12 at 10:30 a.m., an observation noted the staff going in and out of the resident's room with the door left open without protective equipment. Review of Resident #132's clinical record revealed an order on 11/26/12 at 9:00 a.m. for Stool x 1. Continue Contact Isolation until [MEDICAL CONDITION] is resolved. On 11/26/12 at 10:54 a.m., an observation was made of S16CNA entering Resident #132's room with a pillow case without protective equipment on and exiting without washing her hands. On 11/26/12 at 11:04 a.m., an observation was made of a S17CNA entering Resident #132's room without protective equipment on with 2 clear bags of clean linen. Further observation noted S17CNA exiting the resident's room, without washing her hands, with 1 bag of clean linen and entering another resident's room. On 11/26/12 at 11:07 a.m., an interview was conducted with S17CNA. She said that S15LPN informed her Resident #132 was not on Contact Isolation. She confirmed she had 2 clear bags of clean linen with her when she entered Resident #132's room. She said she left 1 bag in Resident #132's room and she took the other clear bag of linen from Resident #132's room to another resident's room. She confirmed that she was not supposed to take clean linen out of Resident #132's room; who was on Contact Isolation, to another resident's room. She also said she put a gown on Resident #132 and transported her to the community bathroom and gave her a shower. She said that after the resident's bath, she took the resident's gown back down the hall to her room without it being in a double lined trash bag and put it in her hamper for her family to wash. On 11/26/12 at 12:53 p.m., while 2 CNA's performed incontinent care; an observation was made of brown soft stool in Resident #132's brief. On 11/26/12 at 12:56 p.m., an interview was conducted with S15LPN. She said that she was not aware that Resident #132 was having 3 and 4 foul loose stools a day because she had been on vacation and the CNA staff had not informed her. On 11/26/2012 at 1:04 p.m., an interview was conducted with S17CNA. She stated she cleaned the shower after she bathed Resident #132 with Potencia U-4. Review of Potencia U4's chemical makeup as S17CNA read it out loud revealed the following: Agua 2-[MEDICATION NAME] Potacio Hidroxido Alto Jabon de Aceite Potasio Tetradosodium [MEDICATION NAME] Fragancia Tenido S17CNA stated she got the cleaning agent that she cleaned the shower with from the housekeeping department already mixed. She said she sprayed it on the shower chair, let it sit for 10 minutes and rinsed it off. She said after she bathed Resident #132, she bathed Resident #32, #68 and #140. On 11/26/12 at 1:41 p.m., an interview was conducted with S18Housekeeping Aide. She stated she got the chemical Potencia U4 out the utility room. She said she put a little water in the bottle and mixed it and gave it to the shower aides to clean with. On 11/26/12 at 1:51 p.m., an interview was conducted with S19Housekeeping Supervisor. She said that Potencia U4 was a Degreaser. She said it was already premixed when the shower aides received it from them. She stated the housekeeping department was responsible for mixing it and giving it to the shower aides. She said the Potencia U4 was not mixed very often. She said it might be a week or so when the shower aides ran out and need to mix some more. She said the bottle of Potencia U4 that S17CNA used to clean the shower after showering Resident #132 had not been mixed recently. She confirmed the bottle that the Potencia U4 was in, did not give any instructions on how long to leave it on for cleaning but there were instructions on the shower in the community bathroom to leave the cleaning agent on for 10 minutes. On 11/26/12 at 2:01 p.m., an interview was conducted with S7Infection Control Nurse. She stated that once the facility found a resident was on Contact Isolation, the protocol was to institute Contact Precautions that day but confirmed the facility obtained a positive lab result for [MEDICAL CONDITION] for Resident #132 on 11/5/12; [MEDICATION NAME] 500 mg for 11/6/12, and an order for [REDACTED]. On 11/26/12 at 2:19 p.m., an interview was conducted with S9ADON. She stated that they have a shower log the shower aides maintained to inform the staff who was bathed. Review of the Shower Log for the hall on which Resident #132 resided revealed Resident #132 had a shower on 11/26/12 given by S17CNA. On 11/26/12 2:28 p.m., an interview was conducted with S15LPN. She confirmed the facility received lab results on 11/5/12 confirming that Resident #132 was positive for [MEDICAL CONDITION] and an order was not obtained until 11/9/12 to place the resident on Contact Isolation. On 11/26/12 at 2:30 p.m., an observation was made of Resident #132's son leaning over her bed without protective equipment; folding her covers back, touching her. Further observation noted that the resident's son walked out of the resident's room without washing his hands. On 11/26/12 at 2:25 p.m., an interview was conducted with S15LPN. She said the resident's son was aware the resident had [MEDICAL CONDITION] but that she had not educated him on the importance of wearing protective equipment and handwashing while the resident was on Contact Isolation and she would talk to him on that day. On 11/26/12 at 3:15 p.m. an interview was conducted with S19Housekeeping Supervisor. She stated the housecleaning department cleaned all the rooms with U1, U4 and CM but confirmed none of them killed [MEDICAL CONDITION]. Review of the literature on the above noted chemicals revealed the following: U4-'This product is truly the most versatile cleaner in anyone's line. A water-based cleaner and degreaser, formulated to remove grease, oil, carbon or any other industrial soil from concrete, machinery, engines, floors, walls, etc. Low foaming for use in automatic scrubbers...(chemical makeup as noted above) U1/CM-germicidals No information given per staff as to what either of these chemicals killed. On 11/26/12 at 4:15 p.m., an interview was conducted via phone with S17CNA. She stated she had been giving residents' showers since around July or August 2012 and she had been using the Potencia U4(degreaser) since then. She stated that whenever she got low in the cleaner, she asked the housekeeping supervisor to refill it. On 11/26/12 at 4:20 p.m., an interview was conducted with S7InfectionControl Nurse. She verified that S17CNA had been working in the shower since May 11, 2012. She stated the CNAs were inserviced on 1/26/11 on how to clean the shower room/shower chair for a resident who had scabies but no documented evidence for a resident with [MEDICAL CONDITION]. She said they were informed to use U1 plus a Germicidal cleaner before and after that resident. She acknowledged that the facility had no documented evidence that the current shower aides had been inserviced on what to clean the shower with for a resident with [MEDICAL CONDITION]. She said that she did not know who told S17CNA to clean the shower/shower chair with U4 and that she was supposed to be cleaning it with U1. She acknowledged U1 did not kill [MEDICAL CONDITION]. She stated that the shower aides received the cleaning supplies for the shower from the housekeeping department but made no mention of who monitored the shower aides when cleaning the shower or what cleaning agents were used. On 11/27/12 11:47 a.m., an observation was made of S18Housekeeping Aide standing in Resident #132's doorway putting on a disposable gown and a hat retrieved from the Isolation Cart near Resident #132's room. On 11/27/12 at 11:48 a.m., an interview was conducted with S18Housekeeping Aide. She stated "I'm about to clean Resident #132's room with "Fresh Breeze TB, I guess". She said she was waiting on her supervisor to come tell her what to clean the resident's room with. On 11/28/12 at 7:37 a.m., an observation was made of S8LPN entering Resident #132's room without a gown, mask and foot covers. S8LPN was observed touching the resident covers and upper extremities. Further observation noted that the resident's family member was touching and leaning over the resident without a gown, gloves, mask, or shoe covers. The family member then retrieved a cell phone out of his pocket and placed in up to his ear and exited the room, without washing his hands. S8LPN removed her gloves, exited the resident's room and returned to her medication cart without washing her hands. On 11/28/12 at 7:39 a.m., an interview was conducted with S8LPN. She stated that she was the staff nurse taking care of Resident #132 and did not know the resident was still on Contact Isolation. She said that resident's family member told her that she still had [MEDICAL CONDITION] and confirmed she did not wear the gown, mask, foot covers or gloves while touching the resident nor did she wash her hands when she came out of the resident's room. On 11/28/12 at 7:40 a.m., an observation was made of S20LPN entering into Resident #132's room without a gown, mask, gloves and shoe covers conversing with the resident's family member. On 11/28/2012 at 7:43 a.m., an interview was conducted with S20LPN. She stated that she did not know Resident #132 was on Contact Isolation and confirmed she did not put a gown, foot covers, gloves and shoe covers before entering the resident's room and was supposed to. On 11/28/12 at 3:12 p.m., an interview was conducted with S2DON. She confirmed the facility staff was not implementing Contact Isolation Precautions for Resident #132 on 11/26/12 because S15LPN told the 100 Hall CNA's, Resident #132 was no longer on Contact Isolation before obtaining a discontinue order. She said the facility staff/family were supposed to be putting on a disposable gown, gloves, mask and shoe covers before entering the resident's room on Contact Isolation and removing the protective equipment before exiting. She acknowledged the staff/family members were supposed to wash their hands before and after providing care for to the resident. She confirmed S17CNA gave Resident #132 who had [MEDICAL CONDITION]; a shower and used Potencia U4(degreaser) to clean the shower; but was supposed to be using U1 which was a germicidal agent. She said the Potencia U4 was not a germicidal agent that it was a cleaner degreaser. She stated U1 was the actual germicidal agent the shower aides were supposed to be using for cleaning the showers; but verified it did not kill [MEDICAL CONDITION]. S2DON acknowledged 3 other residents(#32, #68, #140) were showered after Resident #132 without the shower being disinfected properly with an agent that killed [MEDICAL CONDITION] and should not have been. She acknowledged the facility had not recognized and QA the issues regarding the above noted. Surveyor: Burt, Lisa An interview was conducted on 11/30/12 at 12:55 p.m. with S1Administrator and S2DON. S1Administrator stated she was responsible for the facility ' s QAA committee and that she had conducted her first QAA meeting on 10/31/12. S1Administrator stated that the facility ' s previous Risk Manager had been responsible for the QAA committee but she did not know what areas of concern had been identified because she could not find the documentation of the facility's QAA Meetings held prior to the 10/31/12 meeting. S1Administrator and S2DON verified the facility had not identified that the community shower area had not been disinfected after showering a resident infected with [MEDICAL CONDITION]. In addition, S2DON stated the following problems had not been identified and acted upon by the QAA Committee: 1. The facility was not monitoring weights of a resident who had experienced a significant weight loss. 2. The facility was not monitoring behaviors of residents on antipsychotics. 3. The facility was not resolving grievances. 4. The facility was not providing activities that met a resident ' s interests. 5. The facility had not recognized that the shower aides were not cleaning the shower chair/shower stall with the correct cleaning agent. 6. The facility had not identified that staff and visitors were not wearing personal protective clothing when entering a resident room who was positive for [MEDICAL CONDITION]. 7. The facility had not recognized that staff was not [MEDICATION NAME] good hand washing before and after the delivery of care to residents.

Based on record reviews, and staff interviews, the facility failed to ensure that a resident remained free of accident hazards and received adequate supervision to prevent avoidable accidents for 3 (#1, #2, #3) of 3 (#1, #2, #3) sampled residents out of a universe of 9 residents identified by the facility at high risk for falls. The facility failed to: 1. plan care for newly admitted resident with a history of falls with injury to prevent falls from bed and wheelchair ( #3); 2. ensure that the direct care staff were knowledgeable of their assigned resident's fall/risk status (#3); 3. increase supervision after resident falls (#1, #2, #3); 4. provide adequate supervision of the high risk for falls resident (#1, #2, #3); and 5. revise the care plan with fall prevention approaches following each fall (#1, #2, #3). The Immediate Jeopardy began for Resident #3 when she was admitted on Friday 05-06-11 with a history of cognitive impairment, falls with injury, and the facility failed to put interventions in place to prevent falls from the wheelchair. Resident #3 fell on [DATE], 05/08/11 from the bed. On 05/10/11, the resident fell from her wheelchair in the bathroom. The Immediate Jeopardy was removed for this resident on 5/10/11 when the resident was transferred to the hospital. The resident sustained [REDACTED]. During this hospitalization a Vertebroplasty (non-surgical repair by injection of special cement into the fractured bone) was performed to reduce the pain. The deficient practice continues at an actual harm for this resident and at a potential for more than minimal harm for any resident admitted with a history of injury with falls and is not care planned with interventions to prevent falls from the bed and from the wheelchair. Findings: Review of the facility's Policy and Procedure for falls revealed the following: Standard of Practice Title: Fall Management, Revision - Date: 11/15/2007 Standard: the facility will identify residents at risk for falls and implement interventions to minimize fall occurrences and injury related to falls. The highest practicable level of function will be maintained with the implementation of a fall management program entitled 'Falling Leaf Program'. Practice Guidelines: 1. All residents are evaluated for fall risk upon admission/readmission, quarterly, and with a significant change using the Nursing Evaluation form, Section I Fall Risk Evaluation. A resident is considered to be at risk for falls if the total score is greater than ten (>10). 2. A Fall Risk Evaluation and Care Plan will be completed when the resident is identified to be at risk for falls or has had a fall to ensure that appropriate interventions are put into place. 3. Resident who are identified at risk for falls or has had a fall shall be reviewed by the weekly Standard of Care (SOC) Committee for placement on the 'Falling Leaf Program' which includes: Referral for rehabilitation screen or evaluation....; Referral for Restorative Nursing; Placement of a visual identifier.... 4. The Fall Risk Evaluation and Care Plan is revised after each fall. 6. If a fall occurs, the licensed staff: 6.5 Initiates or revises the Fall Risk Evaluation and Care Plan: To reflect any changes in the resident's status; and address new interventions in place to reduce recurrence of the fall or minimize potential for injury; and resolve any interventions that were in place and determined ineffective for this resident. Review of the facility's protocol for Neurological Assessments revealed the following: A Neurological Assessment is completed if a head injury is suspected or in the event of an unwitnessed fall. Neuro checks are done every two (2) hours for eight (8) hours then every four (4) hours for the remainder of the first twenty-four (24) hours post fall, then every shift for next forty-eight (48) hours, to total seventy-two (72) hours Resident #3: A review of the resident's clinical record revealed in part the following: Resident #3 was admitted to the facility on Friday, 05/06/11 from a local hospital with a [DIAGNOSES REDACTED]. The resident's [DIAGNOSES REDACTED]. Also noted in the record was a history of a Sacral Fracture with Sacroplasty in 2010. Review of the Nursing Evaluation form, dated 05/06/11(Day of admit) revealed a hand written entry under the explanation/comments section as follows: Resident requires extensive assistance with ADLs (Activities of Daily Living) R/T (Related to) impaired mobility, poor cognition, and poor safety awareness; resident attempts to get OOB (Out of Bed) without assistance, high risk for falls. Under section I. Fall Risk Evaluation, the assessment revealed that the resident had 1-2 falls in the past three months and had a total score was 14. This section revealed that if the total score was greater than 10, the resident was a high risk for falls and the Fall Assessment and Care Plan must be completed. Review of the Fall Risk Evaluation and Plan of Care, dated 05/06/11 with goal date of 08/06/11 had the following checked: Chronic or acute condition resulting in physical instability, Fracture and Osteoporosis, as evidenced by ROM (Range of Motion) limitation, ADL assistance required, and Alzheimer's or other dementia as evidenced by impaired judgment. Interventions: Initial interventions were: 05/06/11- PT/OT (Physical Therapy/Occupational Therapy) screen as needed, and call device within reach. Review of the section on the care plan entitled History of falls revealed the following: 04/18/11 prior to admit sustained Right hip fracture and had ORIF 04/19/11 05/07/11- Fall no injury 05/08/11- Fall no injury 05/10/11- Unwitnessed fall no injury. Further review of the record revealed that the resident was sent to the emergency room for evaluation after the above unwitnessed fall on 05/10/11, and was found to have an L2 compression fracture. Review of the Nurse/Physician Communication Record dated Saturday, 05/07/11(1st fall) at 5:45 p.m. and signed by S9LPN revealed: 5:00 p.m.- Notified by resident's roommate's family that resident was on floor. Upon entering room resident was noted to be sitting on buttocks with feet out in front of her. Resident was unable to give account of how she fell , was AAO (Awake, Alert, Oriented) x 1 to self. Was assisted back to bed. Head to toe assessment was performed and revealed an abrasion to the left elbow, base pink, no drainage noted, resident denies pain to area. Resident denies pain upon ROM (Range of Motion). 5:40 p.m.- ______ (Nurse Practitioner) notified, new orders noted for neuro checks per facility protocol, clean abrasion to left elbow with wound cleaner, apply TAO (Triple Antibiotic Ointment) and bandage PRN (As needed) until healed. Review of the Neurological Assessment sheet revealed that neuro checks were implemented at 5:00 p.m. on Saturday 05/07/11. The times of the assessments were every 2 hours until 1:00 a.m. on Sunday, 05/08/11. After 1:00 a.m. it was done one time at 5:00 a.m. on 05/08/11. Review of the Nurse/Physician Communication Record dated Sunday, 05/08/11(2nd fall) and signed by S10LPN at 6:45 p.m. revealed: 6:38 p.m. Resident got up out of bed holding on to drapes bringing body down to floor. Resident was not wearing any shoes, no objects noted in resident's path. Floor was dry. Resident stated, "I was trying to sit on floor to put on my shoes". 6:47 p.m. notified Nurse Practitioner_____ /for Dr.____ (Primary Care Physician) that resident appeared to have fallen. _____Nurse Practitioner gave orders to start neuro checks and monitor resident. Ativan 0.5 mg 1 X dose. Will continue to monitor. Review of the Nurse/Physician Communication Record dated Sunday, 05/08/11(2nd fall) revealed: 05/09/11(Monday)- Reviewed per IDT and all agree that resident will be placed on falling leaf. Updated interventions were documented as follows: 05/09/11- Falling Leaf Program and Low Bed. 05/10/11- No leaving resident unattended when up in wheelchair. Review of the Fall Risk Evaluation and Plan of Care, dated 05/06/11 with goal date of 08/06/11, revealed updated interventions of: 05/09/11- Falling Leaf Program and Low Bed. 05/10/11- No leaving resident unattended when up in the wheelchair. Review of the Nurse/Physician Communication Record dated Tuesday, 5/10/11(3rd fall) and signed by S11LPN at 4:20 p.m. revealed: 4:20 p.m. Called to resident's room by CNA. Resident in bathroom on floor with W/C (Wheelchair) beside her. When asked how she got in the bathroom, resident stated "she rolled herself into the bathroom", checked resident's skin for any tears or bruising, resident stated she did not hit her head, helped resident into W/C, family notified per nursing supervisor, Nurse Practitioner notified of fall , no new orders. (Typed as written in nurse's notes) 5/11/11 ( Wednesday) interventions for post falls- Staff to encourage resident to attend activities and inservice staff not to leave resident alone in room and to notify staff if resident is left alone in room. Review of the Neurological Assessment sheet with the date 05/10/11 revealed resident was checked at 4:20PM and 6:20PM. Review of the Nurse's Notes dated Tuesday, 05/10/11 at 6:30 p.m. revealed: On call Nurse Practitioner was notified of resident's status and the family's concerns. New orders received. Okay to send to local hospital ER for treatment/evaluation R/T (Related to) fall per family request.......When asked to rate pain on scale of 1-10, Resident states, "8". Ultram 100 mg. by mouth administered per MD order to decrease pain level. Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed: Section C - Cognitive Patterns: A Brief Interview for Mental Status (BIMS) score of 3 (0-7 is severely impaired). Section J - Health Conditions: J1700 Fall History on Admission: A.) Did the resident have a fall any time in the last month prior to admission? 1. Yes C.) Did the resident have any fracture related to a fall in the 6 months prior to admission? 1. Yes J1800. Any falls since admission or Prior assessment? 1. Yes J1900 Number of Falls since admission: A. 2- No injury; B. 1-Injury; C. 0-Major injury. Review of the section on the care plan entitled History of falls revealed the following: 04/08/11 prior to admit sustained Right hip fracture and had ORIF 04/19/11 05/07/11- Fall no injury 05/08/11- Fall no injury 05/10/11- Unwitnessed fall no injury Further review of the record revealed that the resident was sent to the emergency room for evaluation after the above unwitnessed fall on 05/10/11, and was found to have an L2 compression fracture. On 06/08/11 at 9:45 a.m. an interview was conducted with S7CNA and she verified that she was working with Resident #3 on 05/10/11 (3rd fall). S7CNA stated on 05/10/11 she heard someone hollering, "She's on the floor". She stated she went into the Resident #3's room and the resident was sitting on the floor of the bathroom leaning up against the wall. S7CNA stated she called for another staff member to come and assist her in getting the resident up into her wheelchair. S7CNA stated that she had not been told during the morning report at shift change that the resident was on the Falling Leaf Program, nor that she was a high risk for falls. S7CNA stated that 05/10/11 was the first day that she had worked with the resident. S7CNA stated that the resident usually had a sitter with her and she did not know why the sitter was not present in the room at the time of the incident. S7CNA stated that when a resident had a sitter present, the staff members would only go into the room to deliver the meal trays and to refill the water pitchers. When S7CNA was asked who she reported the fall to, she responded, "To the nurse on duty at the time." On 06/08/11 at 9:55 a.m. an interview was conducted with S8RN Supervisor. S8RN stated the resident's family informed her when the resident was being admitted on [DATE] that the resident had a history of [REDACTED]. She stated a sitter had been used at home and would continue to sit with resident during the transition into the facility. The surveyor asked S8RN how the CNAs knew when a resident was at high risk for falls. She replied, "When they are on the Falling Leaf Program a leaf is placed on the door of the resident's room and on the wall above the resident's bed. They are told in report when they come on duty and get their resident assignments. Also anyone who is in a low bed is noted to be at high risk for falls". S8RN was asked if the CNA who put resident up in the W/C and left her, knew that the resident was at high risk for falls, and she stated, "Yes". After reviewing the Nurse/Physician Communication Record she verified that the IDT did not review the resident's falls on 05/07/11 and 05/08/11 until Monday 05/09/11. She verified the low bed was implemented on 05/09/11, 2 days after the 1st fall. On 06/08/11 at 10:00 a.m. an interview was conducted with S1LPN Supervisor. S1LPN verified that she was the supervisor over the hall that Resident #3 resided on. After reviewing the resident's record, she stated that she reviewed the resident's falls and made her recommendations on Monday, May 9, 2011 at the morning staff meeting. S1LPN Supervisor verified that she made recommendations for a low bed and that the resident be placed on the Falling Leaf Program on Monday, May 9, 2011, 2 days after the first fall. S1LPN Supervisor was asked when the resident was placed on the low bed, she stated that a low bed was put in place for the resident on Monday. S1LPN Supervisor was asked if the CNA taking care of the resident knew that the resident was at a high risk for falls, she replied she didn't know for sure if the CNA knew this, but that all newly hired CNAs were oriented to the Falling Leaf Program during orientation. S1LPN Supervisor verified that there were no new approaches to prevent falls identified or care planned for 2 days after the first fall. When asked if any inservices had been done to alert the staff to the falls and how to prevent them, S1LPN stated that an inservice was conducted on 05/10/11, after the 3rd fall and after the resident was sent out to the emergency room for evaluation and treatment at a local hospital. S1LPN verified that Resident #3 was admitted to hospital on the same day. S1LPN was asked if there was a certain number of falls that a resident had to sustain before any preventative measures were implemented. She replied, "No". S1LPN Supervisor stated that they start with the least restrictive measures and move up to keep the resident accident free. On 06/08/11 at 10:55 a.m. a phone interview was conducted with S11LPN. S11LPN verified that she had worked with Resident #3 on 05/10/11. S11LPN was asked to give an account of the incident that happened on 05/10/11 regarding the resident's fall. She stated that when she came on duty she was given report that the resident had a history of [REDACTED]. She stated while doing her initial rounds of the residents after the report, she noticed that Resident #3 was in a low bed with the landing mat on the floor at the bedside. There was no sitter present at this time. She stated that she was called to the room by the CNA after the resident fell out of the wheelchair. S11LPN stated she performed a head to toe assessment and documented the incident on the Nurse/Physician Communication Record. She stated that S12CNA, informed her that she did not know the resident was not to be left alone when up in the wheelchair. S11LPN also stated that S12CNA had not worked with the resident before this time. S11LPN verified that S12CNA was assigned to the resident on 05/10/11. When asked if there was an inservice done for the staff to know the resident was high risk for falls and how to prevent them, she stated "Yes", and verified that it was conducted on 05/10/11 after the 3rd fall. On 06/08/11 at 12:15 p.m. a phone interview was conducted with S12CNA. S12CNA was asked to give her account of the incident that happened on 05/10/11, when the resident fell out of the wheel chair. S12CNA stated that when she walked by the room of Resident #3, she noticed the resident sitting up on the side of the bed putting her shoes on. She stated she approached the resident and asked her what she was doing and where was she going. She stated the resident made no reply to these questions. She stated she asked the resident if she wanted to get up in the W/C (wheelchair) and she replied, "Yes". S12CNA stated she assisted the resident to the W/C. S12CNA stated that she asked the resident if there was anything else she needed, and the resident stated "No". S12CNA stated she left the room at that time to go and assist other residents. She stated there were visitors in the room visiting with resident's roommate. S12CNA stated that she was walking toward the back of the hall when she heard a man yell that she fell . She stated that she and another CNA went into the room and got the resident up. S12CNA was asked if she knew the resident was on the facility's Falling Leaf Program and was a high risk for falls, she replied, "No". S12CNA stated that she didn't know what the Falling Leaf Program was. She stated she was not told at the beginning of the shift, when the resident was reassigned to her about the precautions that were to be taken. She stated this was her first time to work with this particular resident and she did not know that she was confused. When asked who she reported the fall to, she replied, "To the nurse on duty at that time." When asked approximately how long was the resident up in the W/C before being alerted to the fall, S12CNA replied she didn't know for sure, but she thought it was 30 minutes. On 06/08/11 at 1:18 p.m. a phone interview was conducted with the daughter-in-law of the resident. The daughter-in-law was asked if the resident had any change in cognition or body functions due to the injury sustained from the last fall at facility. She stated that the resident did have some decrease in cognition. She also stated the resident had and continued to have a lot of pain from the injury. She stated when she is moved she will voice her pain by making sounds and sometimes she states, "My back hurts". The resident's daughter-in-law stated the resident had Sacroplasty done while in hospital after fall on 05/10/11. (Hospital records reveal that Vertebroplasty was the procedure done for the L2 Compression Fracture.) On 06/08/11 at 11:45 a.m. an interview was conducted with Corporate Nurse. The surveyor asked Corporate Nurse if the staff were able to implement preventative fall measures before the IDT team met to discuss issues concerning a resident. She stated that the facility's policy for falls indicated that the licensed staff were to revise the care plan, but the previous DON had deviated from the policy and wanted the team to revise the care plan. The Corporate Nurse stated that she has instructed the staff to not wait for the IDT to implement a safety precaution for a resident that is admitted with a history of falls or that sustained a fall or accident on the weekend,or a holiday when the management staff are not in the building. On 06/09/11 at 12:00 p.m. the Corporate Nurse was interviewed and was asked why the resident was not placed on the Falling Leaf Program on admit, when she was admitted with a history of a fall with a hip fracture. She stated that they had a problem with communication between the admissions office and the direct care staff and they may not have known about it. She stated that when she came to the facility to assist in orienting the new DON (Director of Nursing), she had identified problems with falls. She stated that before she came here, the DON had deviated from the Corporate policy and the staff did not think they could update the care plan and implement any approaches without the SOC (Standard of Care) team. She stated that the former DON had instructed the staff not to add anything to the care plan. She stated that they have since been instructed on implementing measures for resident safety related to falls. After reviewing the resident's record, she verified that the resident had been assessed as high risk for falls and the nursing evaluation on admission indicated she had sustained falls before admit. She verified that the Falling Leaf Program was not implemented until after the resident had sustained 2 falls. The Corporate Nurse stated that part of the Falling Leaf Program was for the staff to check those residents more frequently throughout the day. She verified that the facility's policy was for the licensed staff to assess the resident, investigate the cause of the fall, and determine interventions to prevent further falls. She stated that the care plan should be updated by the licensed staff after each fall. Review of the resident's medical records from ______(local hospital) revealed the following: The Emergency Department Physician Notes, dated 05/10/11 at 9:57 p.m., revealed that the history of present illness was as follows: The patient presents following fall out of wheelchair at 5:00 p.m. today. Patient was left alone and tried to stand after being left unattended. Patient was found on the bathroom floor. Patient complained of lower back pain radiating to bilateral hips.......The character of symptoms is pain. The degree present is moderate. The relieving factor is none.....Associated symptoms: lower back pain, bilateral hip pain, denies nausea and vomiting. Radiology results: Computed Tomography, L-spine and pelvis, acute compression fracture at L2. Impression and Plan: Compression fracture of L2 lumbar vertebra Disposition: Admit: Time 05/11/11 1:24 a.m. to inpatient unit. Resident was in the hospital from 05/11/11 through 05/18/11. A review of the History and Physical dated 05/11/11 and documented by the Orthopedist revealed the following: Chief Complaint-Back Pain History of Present Illness- CT (Computed Tomography) scan showed acute L2 compression fracture. Impression: Fall with L2 or L1 compression fractures. A review of the Minor Procedure Flow sheet pre-procedure dated 05/13/11, revealed that the procedure performed was a Vertebroplasty. Review of the hospital's physician progress notes [REDACTED]. Review of the clinical record revealed that Resident #3 had 3 falls since admit on 05/06/11 and she had a history of [REDACTED]. Review of the clinical record revealed that she had poor cognition, poor safety awareness and that she was at high risk for falls. The record revealed that the only preventative measure identified to prevent falls was to have the call light in reach and a PT/OT screen. When the resident fell out of bed twice the facility then identified new fall prevention interventions, but failed to ensure that the direct care staff were informed of the measures and implemented the preventative measures. As a result Resident #3 sustained a fall from her wheelchair that resulted in a compression fracture of L2. Resident #1 Review of the resident's record revealed that he was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Review of the facility's list of residents that had sustained falls in April and May, 2011 revealed that the resident had sustained falls on 04/11/11, 05/07/11, and 05/14/11. "No injuries", was documented on the list next to each fall. Review of the nurse's notes revealed the following: 04/11/11 at 5:00 p.m., (Monday) Found resident on bathroom floor against wall; no witnesses present; performed skin assessment and neuro checks on resident; no signs/symptoms of distress noted. No complaint of pain..... Will continue to monitor. There was no documented evidence that the nursing staff identified any new interventions to prevent falls or evaluated interventions that were ineffective. 04/12/11 IDT (Interdisciplinary Team) meeting for fall. Recommendation made to encourage resident to use call light to call for assistance. 05/07/11 at 9:10 a.m., (Saturday) Called to resident's room by CNA _____ (S13CNA). Resident visually on his knees beside bed. Asked resident what happened. Resident stated that he slipped onto his backside and he was trying to get his self up. Resident just had socks on his feet, and he stated he lost footing. Resident denies any pain. There was no documented evidence that the nursing staff identified any new interventions to prevent falls or evaluated interventions that were ineffective. 05/09/11 IDT meeting held (2 Days after the fall). Care plan updated with interventions to instruct resident to call for assistance when needed. Re-education reinforced to use call light system. 05/14/11 - 8:30 p.m. (Saturday) Resident found sitting on the floor. It appears resident was trying to have a bowel movement in his garbage can, and slipped down in his own feces, and began to scoot toward the bathroom door. Asked resident what happened, he did not respond..... There was no documented evidence that the nursing staff identified any new interventions to prevent falls or evaluated interventions that were ineffective. 05/16/11 - U/A (Urinalysis) ordered, will obtain a BSC (Bedside Commode), plan of care discussed in clinical meeting this morning. 05/18/11 IDT meeting for past fall (3 Days after fall). Interventions included to offer frequent toileting, after meals, and between meals, falling leaf program and obtain U/A. Review of the MDS (Minimum Data Set) Quarterly assessment, dated 03/24/11, revealed a BIMS (Brief Interview for Mental Status) score of 6 (0-7 is severe impairment). The assessment revealed that the resident needed limited assistance of one person for transfers and extensive assistance of one person for toilet use. Review of the care plan revealed a form entitled Fall Risk Evaluation and Plan of Care with an original date of 02/07/11. The care plan revealed the following: Risk Factors: Cardiac medications, Syncope, Psychotropic medications. As Evidence by: Vital signs, sensory impairment, impaired balance, shortness of breath, easily distracted, impaired judgment, unaware of safety. Hand written in under risk factors was the following: 04/11/11 - Fall 05/07/11 - Unwitnessed fall 05/14/11 - Fall Interventions: VS (Vital Signs), Observe medication side effects, reorient to environment, monitor during shift change, monitor if occurring with syncope, supervise with ambulation, assistive equipment within reach, evaluate toileting needs, call device within reach, minimize room clutter, safety education. Updated Interventions: 04/11/11 - Instruct resident to call for assistance 05/09/11 - Braden Score 19 Frequent staff monitoring. 5/14/11 Fall: Offer Frequent toileting, after meals and between. Falling Leaf Program. Obtain U/A and BSC. There was no documented evidence of any other interventions identified to prevent falls for this resident. On 06/07/11 at 2:15 p.m. S14LPN was interviewed and was asked what interventions were done for prevention of falls for Resident #1. She asked to look at resident's record and stated that she worked weekends. After reviewing the care plan, she stated that she was working on 05/14/11 (Saturday) when the resident sustained [REDACTED]. After reviewing the nurse's notes, she stated that a U/A was ordered on [DATE] (Monday) and a BSC chair was ordered. She stated that after the IDT team evaluated the resident's fall on Monday, following the 5/14/11 fall, frequent toileting was added . She stated that they remind the resident to call for assistance. She verified that resident was cognitively impaired and reminding to use the call light was not an appropriate approach. After reviewing nurse's notes she stated that there was no time frame for monitoring or supervision, just frequent. She verified both falls in May involved the resident trying to use the bathroom. S14LPN stated that the resident had no injuries from the falls. She stated that both falls in May occurred while she was working with the resident . She stated that the resident was able to use the call light at times. On 06/07/11 2:40 p.m. S15CNA was interviewed and verified that she had been assigned to Resident #1. S15CNA stated that the resident needed a little assistance with mobility. She stated that he could do things she would tell him to do. She stated that he could help with his transfers and bathing. She stated that she helped him to the toilet. S15CNA stated that sometimes he would call for assistance and sometimes he would try on his own. S15CNA stated that she checked on him frequently. When asked what frequently meant she stated, "I am always on my hall checking on my people. I am in and out of rooms on the hall." S15CNA verified that she worked the 2-10 p.m. shift 5 days a week. She stated that the resident was confused at times. On 06/07/11 at 3:30 p.m. S17RN, MDS nurse was interviewed. After reviewing the record for Resident #1, she stated that the risk of falls was care planned and stated that the resident had not had any falls at the time of the MDS assessments. S17RN stated that unit managers, the risk manager, therapy, and possibly restorative aides are involved in the fall evaluations - team meetings. She stated that the MDS nurses updated the care plans quarterly and annually only. S17RN stated that the MDS nurses reviewed any updates added by the staff during morning meetings to ensure the resident's safety. S17RN reviewed the resident's MDS dated [DATE], and stated that the resident's BIMS was a 6 and that was severely impaired. After reviewing the care plan, she verified that the only new approach after the 4/11/11 fall was to encourage the resident to use the call light. She verified that this was not an appropriate approach for this resident. On 06/07/11 at 3:45 p.m., the RN Corporate Nurse was interviewed with the DON. After reviewing the fall investigations, care plan, PT screening and Nurse/Physician Communication Records, the RN Corporate Nurse verified that the IDT evaluated the fall on 04/11/11 and recommended the approach to instruct the resident to call for assistance. The Corporate Nurse verified that there were no new approaches identified or implemented after the second fall on 05/07/11. She stated that usually when an approach does not prevent another fall they try a new approach. She also verified that an approach to instruct the resident to use the call light was not an appropriate approach for a cognitively impaired resident. She verified that the care plan was not updated with the facility's Falling Leaf Program until after the resident sustained [REDACTED]. Review of the facility's Policy and Procedure for falls revealed the following: Standard of Practice Title: Fall Management Standard: the facility will identify residents at risk for falls and implement interventions to minimize fall occurrences and injury related to falls. The highest practicable level of function will be maintained with the implementation of a fall management program entitled 'Falling Leaf Program'. Practice Guidelines: 1. All residents are evaluated for fall risk upon admission/readmission, quarterly, and with a significant change using the Nursing Evaluation form, Section I Fall Risk Evaluation. A resident is considered to be at risk for falls if the total score is greater than ten (>10). 2. A Fall Risk Evaluation and Care Plan will be completed when the resident is identified to be at risk for falls or has had a fall to ensur

Based on clinical record review, observations, interviews and review of Policy/Procedures for Wound Prevention/Skin Wound Treatment the facility failed to meet professional standards for residents with pressure sores by failing to: 1) Provide weekly skin assessments to detect the development of pressure ulcers by not performing skin assessments from 1/25/11 through 2/22/11, 3/01/11 through 3/29/11, and on 4/05/11 for Resident #6, a paraplegic, which resulted in the development of Stage IV bilateral sacral/gluteal pressure ulcers and bilateral ischial pressure ulcers with wounds extending to the posterior cortical surface of the scrotum with [MEDICAL CONDITIONS]. This required hospitalization with extensive surgical debridement down to the bone of the sacral wound for Resident #6. 2) Provide weekly skin assessment to detect the development of pressures ulcers by not performing a skin assessment for Resident #4 on 4/11/11 which resulted in the development of a Stage IV pressure ulcer to the right heel with exposed bone. This required outpatient wound care debridement for the resident. 3) Identify and accurately assess pressure areas to a resident's feet when she was admitted to the facility. (Resident #5) 4) Follow the facility Policy/Procedure for Wound Prevention/Skin and Wound Treatment. (Residents #4, #5, #6). 5) Provide clinical supervision and monitoring of staff nurses conducting weekly skin/body audits as per facility policy/procedure for high risk residents with pressure ulcers according to the Braden Scale with a score of (1) on 1/27/11 for Resident #6. The Braden Scale score of 1 means the resident was at a severe risk for developing pressure ulcers. 6) Ensure that the Certified Nurses' Assistant (CNA) checked, documented and reported skin conditions for all residents at risk for pressure ulcers. 7) Revise/update the Care Plan for Pressure Ulcers with appropriate interventions for Resident #6 and #4 who were at high risk for developing pressure ulcers. 8) Provide education to Resident # 6, a paraplegic, regarding the importance of weekly skin assessments in detecting changes in skin conditions and the development of pressure ulcers. Resident #6 is a paraplegic who required weekly body audits. Resident #6 was placed in Immediate Jeopardy on 1/25/11 when the facility failed to have a system of clinical supervision in place to ensure that weekly body audits were being performed for Resident #6. The facility failed to educate the resident on repositioning and the importance of body audits in discovering changes to the skin. The facility failed to discover pressure ulcers for Resident #6 until they were Stage IV severity pressure ulcers. The facility failed to ensure the residents were reminded to turned or be repositioned by staff. The facility failed to educate resident # 6 regarding the importance of weekly skin assessments in detecting early changes in skin conditions. The Immediate Jeopardy ended for the resident on 4/10/11 at 2:40 p.m. when resident #6 was transferred to the hospital. Resident #4 was placed in an Immediate Jeopardy situation on 4/4/11 when the staff failed to perform scheduled weekly body assessments. The facility failed to discover a pressure ulcer to the right heel until it reached Stage IV severity with exposed bone. The Immediate Jeopardy was removed on 4/19/11 at 12:47 p.m. when the resident was transferred to the hospital. The deficient practice continues at an actual harm for residents #6 and #4 and at a level II with the potential for more than minimal harm for the 38 residents the facility determined to be at high risk for development of pressure ulcers. Findings: Resident #6 Resident #6 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His cognitive level was a total of 15 points indicating cognitively intact. The facility Policy/Procedure titled Wound prevention/ Skin and Wound Treatment stated the following...: Practice Guidelines: 1.) Skin integrity and risk will be initially evaluated on admission, then weekly times four (4) after admissions or readmissions, quarterly and with a significant change using the Braden Scale which addresses tissue tolerance and factors increasing exposure to pressure. ** There was no documented evidence noting the skin integrity was evaluated quarterly. 2.) All residents who score (18) or less will have a Skin Risk Evaluation and Care Plan initially upon discovery of risk or development of any pressure area. The plan of care will include: 2.1 Interventions are based on the wound, resident's medical condition, resident's mental, physical and psychosocial abilities/disabilities; they include but are not limited to: 2.1.2 If the resident is incontinent: 2.1.2.1 Apply a skin protectant three to four (3-4) times a day to the affected area(s); 2.1.2.2 Apply a moisture barrier/ointment to surround skin. ** There was no documented evidence that the above two interventions were performed. 2.1.3 Position resident off of affected area(s) when possible. ** During an interview with S12CNA on 4/20/11 at 10:00 a.m., he said that he did not assist Resident #6 with turning and repositioning because he was independent in his care and a private person. 2.1.4 Up in chair if tolerated; reposition based on Braden Scale and/ or tissue tolerance document specifics time frames in plan of care interventions. ** There was no documentation indicating that Resident #6 was repositioned while in his wheelchair. The last time Resident #6's Care Plan was updated for Skin Risk Evaluation and Plan of Care was 5/04/09. The interventions listed on the Care Plan contained a box to check if it applies. There was no boxes checked for any of the interventions that could have been utilized. 2.1.8 Inspect skin daily, pay particular attention to bony prominences and areas associated with medical devices. ** There was no documented evidence that Resident #6 had daily skin inspections. 2.1.9 Range-of-motion (ROM) exercises according to restorative plan and evaluation of needs. ** There was no documented evidence indicating ROM exercises were performed. 2.1.12 Measure size of pressure area and evaluate/document findings per standards of practice. 3.) All residents at risk will have skin condition checked and documented daily by the Certified Nurse's Assistant (CNA) on the CNA Flow Sheet. 3.1 The CNA will notify the nurse of positive skin checks via written memo using CNA Notes (Post-it Communication), marking on the body figure appropriately. 3.2 Turning and repositioning will be acknowledged by documentation of the CNA initials on the CNA Care Flow Record per care plan instructions. **An interview was held with S12CNA on 4/19/11 at 10:45 a.m. He said that he worked with Resident #6 once or twice a week. He said that the resident bathed himself and he would bring him towels. He also said that he never assisted him with his bath. S12CNA said that he would change resident #6's bed sheets after the resident pulled the sheets off his bed and placed them in the bin. He also said that prior to the resident going into the hospital he had changed his sheets and did not notice any odors or drainage on them. **A second interview was held with S12CNA on 4/20/11 at 10:00 a.m. He said that he did not inspect resident #6 skin at any time because he was a very private person. He also said that he did not assist him with turning and repositioning. 5.) All residents will have skin checks completed weekly and documented on the weekly Skin Condition Evaluation form. This form will be kept in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Skin integrity, color, moisture, temperature and turgor will be addressed. 9.) 9.1 Inspect skin daily especially over bony prominences and sites that may have impaired circulation due to positioning or from use of medical devices. ** There was no documented evidence stated daily skin inspection was conducted. 9.14 A resident should be taught/ reminded to shift his/her weight approximately every fifteen (15) minutes while in a chair. ** There was no documented evidence that the resident was reminded to shift his weight every 15 minutes. Review of the facility Weekly Skin Condition Evaluation revealed the following documentation: 1/25/11: No skin issues noted. S16LPN 2/01/11: No skin issues noted. S16LPN 2/08/11: No skin issues noted. S16LPN 2/15/11: No skin issues noted. S16LPN 2/22/11: No skin issues noted. S16LPN 3/01/11: No skin issues noted. S16LPN 3/08/11: No skin issues noted. S16LPN 3/15/11: No skin issues noted. S16LPN 3/22/11: No skin issues noted. S16LPN 3/29/11: No skin issues noted. S16LPN 4/05/11: No skin issues noted. S16LPN ** Resident #6 was admitted to a local medical center with a Stage IV sacral decubitus ulcer on 4/10/11 at 2:40 p.m. . Review of the facility monthly summary for February, 2011 and March, 2011 performed by S16LPN stated that resident #6's skin status was good for both months. An interview was held with S16LPN on 4/19/11 at 3:35 p.m. She said she started working at the facility in January, 2011. She also said that she became resident #6's nurse at the end of January for the 2 p.m. to 10 p.m. shift. S16LPN said that during her one day orientation with a former LPN she was told that Resident #6 was a very private person. She said she was also told not to worry about assessing his skin because he may not let you and this was ongoing. She also said that she was told to ask resident #6 if he had any skin issues and to document whatever he said on the weekly skin condition evaluation form. S16LPN said that she was aware that resident #6 was paralyzed from the waist down and had no feelings or sensation from the waist down. She said that she was only doing what she was oriented to do. She also said that she did not inspect or assess resident #6's skin front or back. S16LPN said that once or twice she would ask resident #6 to assess him, but he would refuse. She also said that she did not report any of the refusals to the Charge Nurse, DON nor the resident's Physician. During an interview with Resident #6 on 4/19/11 at 10:20 a.m., he said that S16LPN became his nurse in January of this year. He also said that weekly the LPN would come into his room and ask him if he had any skin issues and he would say "no". He said that he does not recall how many times that he may have refused to have his skin assessed. but S16LPN stopped asking him a long time ago. Resident #6 said that if this was a problem his Physician nor the Nurse Practitioner never mentioned it or brought this issue to his attention. Review of the Braden Scale dated 01/27/11, Resident #6 was given a score of (1) indicating he was at severe high risk for developing pressure ulcers. Review of the MDS (Minimum Data Set) Annual assessment dated [DATE] revealed that the resident had no pressure ulcers. Section M150: Risk for Pressure Ulcers; Yes. M0210: Current Number of Unhealed Pressure Ulcers; 0. Review of the MDS Quarterly assessment dated [DATE] revealed that the resident had no pressure ulcers. Section M150: Risk of Pressure Ulcers; 0. M210: Current Number of Unhealed Pressure Ulcers; 0. Review of Resident # 6 Plan of Care revealed the following...: Original Date: 5/04/09. Risk Factor/Problem: Has the following skin conditions and/or wounds (describes) Stage IV Left Hip. As evidenced by: No redness, no malodor, no increased temperature, no purulent drainage. Goal: Skin will remain intact and will experience no skin breakdown through next review. Wound and/or skin Condition (specific goal): Will remain free from infection. Goal Date: 8/04/09, 11/10/09, 2/10/09, 5/10/10, 8/11/10, 11/03/10. Interventions: **There were no boxes checked indicating interventions were utilized. An interview was held with S8LPN/MDS on 4/21/11 at 8:10 a.m. After reviewing resident #6's care plan she confirmed that the last time the skin assessment care plan was updated/ revised was 5/04/09. She also said that when she started working at the facility his wound had already healed which was documented on his care plan. S8LPN said that even though the wound had healed he was still at risk for developing pressure ulcers because he was a paraplegic. She said that there should be an at risk skin care plan in place, but she was not responsible for doing this. She also said that there was a care plan meeting at the end of March, 2011 and the resident's skin condition was discussed and there was no skin issues voiced at the meeting. An interview was held with S21LPN MDS on 4/21/11 at 8:20 a.m. She also confirmed that Resident #6 skin assessment care plan had not been updated since 5/04/09. She said that the nurses were responsible for the admit evaluation and the quarterly assessment. S21LPN/MDS said that the nurses would perform the Braden scale and implement the skin assessment care plan. She said that the nurses were responsible for initiating all at risk skin care plans and she was responsible for the diseases and the ADLs (activities of daily living). A second interview was held with S8LPN MDS on 4/21/11 at 8:30 a.m. She said that when she started working at the facility they had nurse consultants doing all of the skin audits. She said that she was told that she was not responsible for the skin assessments on the care plans. She also said that she was told to do the diseases and the ADLs of the care plans. During an interview with S10LPN Unit Manager on 4/21/11 at 8:35 a.m., she also confirmed that the skin assessment care plan had not been updated or revised for resident #6. She said that in the past the wound care nurse was responsible for care planning and updating all high risk residents' skin assessment and all active pressure ulcers residents. An interview was held with S1DON on 4/21/11 at 8:35 a.m. She also confirmed that resident #6's skin assessment care plan had not been updated since 5/04/09. She said that where she came from the MDS nurses were responsible for updating the skin assessment care plans. She also said that the Unit Managers were responsible for the daily up keep of all high risk pressure ulcers residents. S1DON said that she was not sure what the policy stated here, but she was accustomed to what she had mentioned above as the way the skin assessments/care plans should have been handled. S1DON said that she would review the policies on skin assessment and care plans because there seemed to be a lot of confusion on what the nurses should do and she was not aware of their roles and what they should be doing. During a second interview with S1DON on 4/21/11 at 9:20 a.m., she said that she must apologize for thinking the MDS nurses was responsible for the skin assessment care plan; "I was wrong." She also said that she have been a nurse for over [AGE] years and it was always done that way. She also said that she does not know what the nurses' roles were and who should be responsible for what duties. Resident #4 Resident #4 was an [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. The most recent Minimal Data Set ((MDS) dated [DATE] in Section C0500 revealed the resident's cognitive status summary score to be a 3; Severe impairment. Review of the MDS Quarterly assessment dated [DATE] revealed that the resident had no Pressure Ulcers as noted below: Section M150: Risk for Pressure Ulcers, 1 Yes M0300: Current Number of Unhealed Pressure Ulcers. 0 Review of the MDS Quarterly assessment dated [DATE] revealed that the resident had no Pressure Ulcers as noted below: Section M0150. Risk of Pressure Ulcers 1. Yes M0300. Current Number of Unhealed Pressure Ulcers 0 Review of the facility's Weekly Wound Assessment document on 4/12/11 revealed that Resident #4 developed a facility acquired Stage IV to his right medial foot. Silvagel treatment was started on 4/12/11. Review of the Nurse/Physician Communication Narrative Nursing Notes on 4/11/11 at 9:30 p.m. written per S3RN revealed the following: Upon inspection of Resident #4, a pressure wound was discovered to his right lateral foot. The wound was red, hot to touch and had bone exposed. The physician and S2RN Wound Care were immediately notified. Orders for an X-ray and [MEDICATION NAME] q 3 days were given verbally by the physician ... Review of the Comprehensive Plan of Care for Skin Risk Evaluation dated 12/10/10 with the date crossed out, revealed that the resident was at risk for skin breakdown and had the following skin conditions and/or wound. Redness to groin/scrotum. Goals: Skin will remain intact and will experience no skin breakdown through next review. Wound and/or skin condition (specific goal) Skin will show signs of healing. No further breakdown by next review. Interventions: I. Braden Score 15-18 (mild risk) A. Skin care (1) Cleanse skin at time of soiling. (2) Minimize exposure to moisture due to incontinence, perspiration or wound drainage. (3) Use absorbent briefs and/or under pads. (4) Turn every 2 hours and as needed (prn). B. Mobility/Activity Deficit for Bed-bound Residents. (1) Use pillows to protect bony prominences. (2) Use pillows or devices that relieve pressure on heels. (3) Reposition every (q) hours. (4) Apply pressure-reducing support surface or dynamic pressure-reduction surface to be as indicated by resident's individual circumstances. (5) Check efficacy of pressure redistribution and/or pressure relief. (6) Screen by Physical Therapy/Occupational Therapy for rehabilitation potential. II. Braden Score 13-14 (moderate risk) (1) Implement all appropriate interventions in previous category. III. Braden Score<12 (high to severe risk) (1) Implement all interventions from previous category. 4/12/11-Stage IV to right foot. Goal: Wound will show evidence of healing by review date as evidenced by positive granulation tissue and decrease in size. Interventions: ABI Arterial Vascular Studies Registered Dietician consult: Vitamins, MVI, Vitamin C and Zinc. Review of the Braden Scale dated 3/25/11 revealed that the resident was a 12; High Risk for a Pressure Ulcer. Review of the physician progress notes [REDACTED]. 4/5/11-Physical Exam performed per physician. Resident had no rashes or bruises noted to his skin and no [MEDICAL CONDITION], joint tenderness and no [MEDICAL CONDITIONS]. 3/8/11-Physical Exam performed. Resident had no rashes and bruises to his skin and no [MEDICAL CONDITION], or joint tenderness. 2/8/11-Physical Exam performed. Resident had a right foot callous to the heel and a left [MEDICAL CONDITION]. 2/2/11-Physical Exam performed. Resident had a right foot lateral heel callous. 12/20/11-Physical Exam performed. Resident had a dry callous to his right heel; intact. Review of the Weekly Skin Condition Evaluation revealed the following: 1/3/11- Still having some redness at scrotum, groin and buttock area. Treatment being done. No new issues. 1/10/11-No new skin issues. Treatment applied to ears and penis. 1/17/11-Pressure ulcer to right buttocks (old). Redness to right and left buttocks and scrotum. 1/24/11-No new skin issues. 1/31/11-Skin at buttocks red; perineal area red; applied moisture barrier cream. 2/7/11-No skin issues at this time. 2/14/11-No skin issues. 2/21/11-No new skin issues. 2/28/11-Redness to buttocks; blanchable. 3/7/11-Skin tear to right elbow; dressing intact. 3/14/11-Skin tear healed to right elbow. 3/21/11-Skin intact, Normal, warm and good. 3/28/11-Skin intact, normal and warm. 4/4/11-No skin audits done for the resident. 4/11/11-Pressure wound to right lateral foot; red, hot and bone exposed. Upon inspection a pressure wound was located on the right lateral foot; red and warm to touch; bone exposed documented by S3RN. On 4/18/11 at 12:21 p.m., an interview was conducted with S5Staffing Education Director. She stated that she asked S6CNA if she saw the wound to the resident's right heel. She stated that S6CNA informed her that she knew he had a sore on his ankle, and that she thought it was already being treated. She stated that S6CNA informed her that it was bleeding one day. She stated that she asked if she report it to the nurse, she said no. Review of the facility's Investigation documentation dated 4/12/11 at 9:30 p.m. revealed that a Stage IV Decubitus was found on the resident 's right inner ankle. Treatment orders were obtained to clean the wound with wound cleanser; apply [MEDICATION NAME] gel with [MEDICATION NAME] tape every 3 days and an X-ray on 4/12/11 in the am. Summary of Incident/Allegation are as noted below: A wound was found by S3RN on 4/11/11 at 9:30 p.m., while doing her body audit. Body audits were not done by S3RN on 4/4/11 on the resident. She stated that she did not do any body audits on 4/4/11 because she was not aware of policy to perform body audits. Conclusion of Investigation: Wound was found by S3RN on 4/11/11. Body audits were not performed on 4/4/11 on any of S3RN's residents due to the fact that she was unaware of policy for body audits. S6CNA performed a bed bath on the resident on 4/11/11 but did not observe the wound at that time. Describe actions taken to protect this resident and to prevent the incident from recurring: Tertiated wound care treatment as ordered. Staff educated in the importance of turning resident q 2 hours and being aware of all body aspects especially bony prominences. Staff educated on performing body audits. On 4/18/11 at 12:25 p.m. an interview was conducted with S8MDS Nurse. She verified that she did not have any other Comprehensive Care Plans for the Skin for Resident #4. She stated that the wound care nurse did the resident's care plans for the skin. On 4/18/11 at 12:29 p.m. an interview was conducted with S3RN. She stated that she found the Stage IV pressure ulcer to the resident's right foot on 4/11/11 while she was doing the body audits. She stated that the bone was exposed and it was red and warm to the touch. She stated that they performed 2 resident's body audits a day on the 2 p.m. to 10 p.m. shift. She stated the week of 4/4/11, was her first week and she was not trained to do skin audits. She verified that when she did the skin audit on 04/11/11 the resident did not have heel protectors on when she discovered the wound. She stated that the resident was supposed to be turned every two hours. She stated that he was in the bed when she found his wound. She verified that the CNAs were supposed to report to the nurses when they found some abnormalities. She said that S6CNA did not report anything abnormal to her when she bathed Resident #4 the morning of 4/11/11 when the Stage IV to the right lateral heel was found. On 4/18/11 at 12:30 p.m. an interview was conducted with S6CNA. She stated that the resident usually wore a gown, diaper and a sock to his right lower leg. She stated that she usually removed his sock when she bathed him, but that she did not see the Stage IV wound to his right foot. She stated that when she found something abnormal, she reported it to the nurse. She stated that the resident gets turned every 2 hours. She stated that the resident wore a heel protector to his right foot, but she said that he did not have a heel protector in place 4/11/11 when she bathed him which was the day the wound was discovered by S3RN. She verified that the resident was supposed to wear the heel protector every day. She stated that Resident #4 could talk. She stated that when she wiped between his toes sometimes, he might say that hurt. She stated that she just always thought that was his skin peeling off. On 4/18/11 at 12:41 p.m. an interview was conducted with S2RN Wound CareNurse . She verified that was the only Comprehensive Plan of Care plan for the resident's skin was dated 12/20/10. She stated that on 12/20/10, the date the Care plan for the skin was dated was the first time she became aware the resident had a problem with his skin. She verified that the care plan was not updated to reflect the following orders: 4/11/11-Cleanse wound with wound cleanser. Apply [MEDICATION NAME] gel, [MEDICATION NAME] in a.m. times 3 days. X-ray ordered for 4/12/11 in the a.m. 4/12/11-No tub or showers. No socks to right foot. Prevalence boot tonight to lower extremities at all times. Nurses to remove each shift q 8 hrs to do neurochecks/vascular checks. 4/12/11-Ankle Brachial Index (ABI) studies with toe pressures to right lower extremities. Referral to the wound care clinic to evaluate and treat wound. Multivitamin 1 by mouth (po) daily. Vitamin C 500 milligrams (mg) po daily. Zinc 220 mg po daily to promote wound healing. 4/12/11-Draw Pre-[MEDICATION NAME] in a.m. Registered Dietitian consult to adequate calorie/powder with tab to promote wound healing. 4/13/11 Order Clarification: Arterial Ultrasound to right lower extremities with ABI. 4/14/11-Change frequency of dressing changes to right medial foot wound to q other day using Silvagel to wound bed. Xenderm to perineal area. Cover with [MEDICATION NAME] tape . Treatment to begin on 4/15/11. On 4/18/11 at 2:45 p.m. an observation was made of Resident #4 lying in the bed resting with his eyes closed on a low air loss mattress with a heel protector to his right foot lying on top of the bottom sheet. Further observation noted that the resident's heel was not floated and there was no turn schedule posted as to when to turn the resident. On 4/18/11 at 2:47 p.m. an interview was noted with S4CNA. She verified that the resident did not have a heel protector to his lower right foot and that his right heel was not being floated. She stated that she determined which side the resident was to be turned on by the side she found him on when she came on the shift. She verified that there were no times written on the turn schedule to tell the CNAs what side the resident should be lying on. On 4/18/11 at 2:55 p.m., an interview was conducted with S1DON . She stated that the nurses let the CNAs know who needs to be turned. She verified that there was no consistent method implemented for the CNAs to use to let each other know when the resident needed to be turned. On 4/18/11 at 3:08 p.m. an interview was conducted with S7Unit Manager. She stated that the CNAs were instructed to turn the resident every 2 hours, but verified that there was no consistent method for the CNAs to use to let each other know when a resident needed to be turned. On 4/19/11 at 8:19 a.m. an interview was conducted with S6CNA. She stated that she was not aware of the Stage IV to the resident's right heel. She stated that when she was interviewed by S5LPN Staffing Education Director on 4/13/11, she thought that she was talking about an old wound that the resident had that was healing. She verified that she bathed the resident the morning of 4/11/11 when S3RN discovered the Stage IV to the resident's right heel with the bone exposed. Review of documentation by S20LPN revealed the following dates: 3/14/11-Skin tear healed to right elbow. 3/21/11 and 3/28/11-Skin intact, good, normal and warm. On 4/19/11 at 10:06 a.m. an observation was made of Resident #4;s heel not being floated and was lying directly on his bottom sheet wrapped with gauze and tape. S2RN Wound Care performed Resident #4 's wound treatment which revealed a quarter-sized Stage IV pressure ulcer to the resident's right lateral foot with pink granulated tissue to the wound bed. No drainage noted at present. On 4/19/11 at 11:27 p.m. an interview was conducted with S1DON. She stated that S3RN missed the body audit on 4/4/11. She stated that Administration became aware of the Resident #4's Stage 4 pressure ulcer on 4/11/11. She stated that she made the assumption that the Unit Manager was going along with the nurses to do the body audit, but they were just checking the body audit sheets and not actually doing the body audits with the nurses. She stated that there were flaws in checking the body audits. On 4/20/11 at 12:00 noon an interview was conducted with S6CNA. She stated that the resident had 2 pillows. She stated that 1 went under the resident head and the 2nd pillow; the resident liked the second pillow under his it under his right knee. She verified that she did not float the resident's right heel and that she put the pillow under his right knee. Resident #5 Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation was made of resident #5 on 4/18/11 at 10:30 a.m. The resident was lying in bed on her back, feet and heels were pushed up against the footboard of her bed. The resident responded to voice only by nodding her head. She was receiving a tube feeding per Percutaneous Endoscopic Gastrostomy (PEG) tube. She had a Foley Catheter draining clear yellow urine. During observation of the resident's skin by S9CNA who entered the room, at the same date and time, revealed there was no breakdown on the resident's skin, but there were dark non-blanchable areas on both heels. An interview with S9CNA on 4/18/11 at 10:35 a.m. who had been assigned to care for the resident, revealed she was not aware that the resident had the pressure areas on her heels and she had not been informed of any interventions to prevent pressure sores for the resident. When asked how often the resident should be repositioned, she replied, every morning and every afternoon. An interview was held with S8MDS on 4/18/11 at 11:10 a.m. She verified that she had assessed the resident on 4/15/11 when the resident was admitted . She had noted dark areas to her heels and described them as dark areas that felt mushy and did not blanch. She said she had documented the assessment and had given the assessment to the Treatment Nurse. A copy of the assessment was requested. When asked again for the assessment on 4/18/11 at 2:10 p.m., she said she was mistaken, she had left a note for S3RN (weekend treatment nurse) but had not documented her assessment. An interview was held with S3RN, Weekend Treatment Nurse on 4/18/11 at 12:40 p.m. She said she had completed a skin assessment for the resident on 4/16/11. She said it was located on the resident's chart. She said she had identified that the resident had dark areas on her heels and that the dark area on her right heel felt "boggy". She said the resident's heels should be floated for prevention, and closely supervised for breakdown. After reviewing the resident's clinical record, she verified she had not included the resident's heels in her assessment. She said she had not requested physician's orders [REDACTED]. Review of the resident's clinical record revealed there was no care plan on the record. An interview was held with S 10 Unit Manager on 4/18/11 at 1:00 p.m. She stated she was not aware that the resident had dark areas on her heels or that her heels needed to be floated. After reviewing the clinical record, she verified there was no care plan on the chart. An interview was held with S1DON on 4/18/11 at 12:00 p.m. After reviewing the clinical record, she verified there was no care plan on the record. She verified the admission assessment on 4/15/11 and assessment by the weekend treatment nurse did not include an assessment of the resident's heels. She said the resident had been admitted on [DATE], but an interim care plan should have been placed on her chart. She verified the resident had not been assessed accurately, or interventions put into place by the staff which placed the resident at risk for the development of pressure sores.

Based on observations, record review and interview the facility failed to: 1) Provide weekly skin assessments to detect the development of pressure ulcers by not performing skin assessments from 1/25/11 through 2/22/11, 3/01/11 through 3/29/11, and on 4/05/11 for Resident #6, a paraplegic, which resulted in the development of Stage IV bilateral sacral/gluteal pressure ulcers and bilateral ischial pressure ulcers with wounds extending to the posterior cortical surface of the scrotum with [MEDICAL CONDITIONS]. This required hospitalization with extensive surgical debridement down to the bone of the sacral wound for Resident #6. 2) Provide weekly skin assessment to detect the development of pressures ulcers by not performing a skin assessment for Resident #4 on 4/11/11 which resulted in the development of a Stage IV pressure ulcer to the right heel with exposed bone. This required outpatient wound care debridement for the resident. 3) Provide clinical supervision and monitoring of staff nurses conducting weekly skin/body audits as per facility policy/procedure for high risk residents with pressure ulcers according to the Braden Scale with a score of (1) on 1/27/11 for Resident #6. The Braden Scale score of 1 means the resident was at a severe risk for developing pressure ulcers. The facility failed to ensure that the Certified Nurses' Assistant (CNA) checked, documented and reported skin conditions for all residents at risk for pressure ulcers. 4) Revise/update the Care Plan for Pressure Ulcers with appropriate interventions for Resident #6 and #4 who were at high risk for developing pressure ulcers. 5) Provide education to Resident # 6, a paraplegic, regarding the importance of weekly skin assessments in detecting changes in skin conditions and the development of pressure ulcers. Resident #6 is a paraplegic who required weekly body audits. Resident #6 was placed in Immediate Jeopardy on 1/25/11 when the facility failed to have a system of clinical supervision in place to ensure that weekly body audits were being performed for Resident #6. The facility failed to educate the resident on repositioning and the importance of body audits in discovering changes to the skin. The facility failed to discover pressure ulcers for Resident #6 until they were Stage IV severity pressure ulcers. The Immediate Jeopardy ended for the resident on 4/10/11 at 2:40 p.m. when resident #6 was transferred to the hospital. Resident #4 was placed in an Immediate Jeopardy situation on 4/4/11 when the staff failed to perform scheduled weekly body assessments. The facility failed to discover a pressure ulcer to the right heel until it reached Stage IV severity with exposed bone. The Immediate Jeopardy was removed on 4/19/11 at 12:47 p.m. when the resident was transferred to the hospital. The deficient practice continues at an actual harm for residents #6 and #4 and at a level II with the potential for more than minimal harm for the 38 residents the facility determined to be at high risk for development of pressure ulcers. Findings: Resident#6 Resident #6 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His cognitive level was a total of 15 points indicating cognitively intact. An interview was held at a local medical center on 4/19/11 at 10:20 a.m. with Resident #6. He said that the last time the nurses looked at his skin was over a year ago when they were doing wound care on his wound. He said the last time the nurses asked him to perform a weekly body audit was over (7) months ago. He also said that he had refused the weekly body audits a couple of times and the nurses just stopped asking him. Resident #6 said that the nurse would come in his room weekly and ask him if he had any skin issues and he would tell her "no" and that was the end of the conservation. He also said that he was paralyzed waist down and had no feelings, so he thought that he did not have any skin issues because the wound that he was admitted with was healed. He said he could not tell if he was having any skin breakdown. He stated that over (7) months ago when the staff stopped doing the body audits, the nurse knew that he had no feelings from his waist down. Resident #6 said that he was never approached by the Physician or the Nurse Practitioner about being non compliant with his care by refusing body audits. He also said that the times he refused to have the weekly body audits done, the nurse came in his room to perform the audit without gloves. Resident #6 said that he reported this to the former administrator. He said that the situation was not resolved so he contacted the Ombudsman to mediate. He also said that the Ombudsman came, but he felt there was no resolution. Resident #6 said that the staff became aware of him reporting this issue and they stated having attitudes against him. Resident #6 said that on Sunday, 4/10/11 he told the weekend nurse that he was not feeling well and he thought he might be coming down with an infection. He said the nurse asked could she assess him and he told "yes". He also said that he could see from the expression on the nurse's face something was wrong with his back area. Resident #6 said he asked the nurse if something was wrong and she said that something was very wrong and it was bad. He said the nurse went to get the RN supervisor to re-assess his back. He said that the RN Supervisor told him that he had a Stage IV sacrum wound and they would send him to the emergency room to be evaluated. Resident #6 said that if the staff had explained to him that the weekly body assessment was very important, even though his other wound was healed he would have let them assess him daily if needed. He said they had become so accepting of what he had told them about not having skin issues. He said he felt he was fine and was concentrating on being discharged . He said that the S17LPN started caring for him at the end of January 2011. Resident #6 said that S17LPN had her weekly routine and would ask him if he had any skin issues? He said that he would say "no" and this continued on until he was sent to the hospital. Review of the Nurse/Physician Communication Record dated 4/10/11 noted the following information...: Reason you are calling/current condition: Sacral opening- Patient stated "was there 2 days ago". On visual inspection yellow drainage with odor noted. (But he didn't tell anyone). Pain/Location: Resident stated when ask to rate pain on scale of 0-10, stated it feels like an infection. Outcome/MD order: To local medical center for evaluation. An interview was held with S10LPN/ Unit Manager on 4/19/11 at 10:30 a.m. She said she was very familiar with Resident #6. She said that she was aware that he gave his own baths, but she was not aware that he was not allowing the nurses to do skin audits. She also said that she did not recall seeing documentation that resident #6 refused to let the nurse conduct body audits. S10LPN/Unit Manager said that she would receive body audits every couple of days to ensure they were being completed. She also said that resident #6 pressure ulcer was discovered by the weekend nurse and he was sent to the hospital. Prior to his hospitalization she said she was not aware of any skin break down. S10LPN Unit Manager said that she had not checked the resident for pressure ulcers and he was a very private person. She said the practice of the unit nurses was to notify the Unit Manager when the resident refused a weekly body audit and to document the resident's refusal. She also said that she went into the resident's room daily and never noticed any odor or drainage. S10LPN said that the body audits were documented as being completed by nurses and nothing was noted about the resident refusing weekly body audits. An interview was held with the facility Nurse Practitioner on 4/19/11 at 1: 15 p.m. He said that on 04/10/11 he received a call from the weekend nurse stating that Resident #6 had a Stage IV sacral decubitus ulcer and needed to go to the hospital for evaluation. He said in the same breath, she said that the resident had been refusing to have weekly skin/ body audits. He also said that this was the first time that he was told that resident was refusing the weekly skin/body audits. The facility Nurse Practitioner said that the nursing facility was a 24- hour nursing care facility which should had provided his care. An interview was held with S15MSW on 4/19/11 at 3:20 p.m. She said that when she first became aware that Resident #6 had a Stage IV ulcer and had been refusing weekly skin audits was after he was admitted to the hospital. She also said that she and Resident #6 had a good rapport and she was assisting him with obtaining housing once he was discharged from the facility. S15MSW said that they have daily morning meetings and there was no mention of this being a problem with resident #6. She also said that there was an annual plan of care meeting on 03/30/11 and the subject never came up. She said had she known, she would have intervene and explain to him why the weekly skin audits were needed. An interview was held with S1DON (Director of Nurses) on 4/19/11 at 4:15 p.m. She said that on Sunday, 04/10/11 she had received a call from the weekend nurse in the afternoon. She said that the weekend nurse was so upset that she could hardly understand what was being said. She also said that she was told that Resident #6 had a Stage IV pressure ulcer and was sent to a local medical center for evaluation. S1DON said she was also told that Resident #6 had refused some weekly body audits and no one has been assessing him. She also said this was the first she had heard that the resident had refused weekly body audits and the audits were not being performed. An interview was held with S13LPN on 4/19/11 at 10:25 a.m. She said that she was the 6 a.m. to 2 p.m. nurse for resident #6. She started working at the facility after the resident's first wound had healed. She said that when he was having a problem he would usually tell the staff. S13LPN stated that the resident was in chronic pain would let the staff know what he needed. She said the only time she would see his body if she walked in during his bath. She also said that the resident never complained of a wound to his buttocks nor did she smell any odor or see any drainage. S13LPN said that resident #6 told the staff that he would check his skin using a mirror. She said that she had not done any of his body audits because it was conducted by the 2 p.m. to 10 p.m. shift nurse. An interview was held with S19LPN on 4/20/11 at 8:30 a.m. via phone. She said that she works at the facility on weekends. She said that she recalled doing a body audit on resident #6. She also said that he would let her check everywhere except his "bottom". She said he would just tell her his bottom was okay. Informed by this surveyor that the body audit performed by her dated 1/11/11, documented no skin issues and there was no documentation stating that the resident did not allow her to check his buttocks/sacral area. S19LPN said that she could not remember if she documented that he refused for his backside to be checked, but if he did then she would have charted it in the nurses' notes. Review of the nurses' noted dated 1/05/11- 1/25/11 did not note any documentation of resident #6 refusing to have his backside assessed or checked. An interview was held with S17Administrator on 4/20/11 at 8:45 a.m. She said that she received firsthand knowledge of Client #6 having a stage IV pressure ulcer on Wednesday (4/13/11) following his Sunday admission to the hospital. She also said that she was not aware of him refusing weekly body audits. Resident #6 was transferred and admitted to a local medical center on 4/10/11. According to the Emergency Department chart dated 4/10/11 the following was revealed...: Chief Complaint: Decubitus ulcers. [MEDICAL CONDITION] Areas over buttocks appear infected. Areas over groin appear infected. Nursing Continuation Notes...: Stage IV decubitus noted to sacral area. Critical Hemoglobin of 5.0 and hematocrit of 17. Patient stated decubitus on sacrum healed approximately 10 months ago. He began to have increased pain and body aches x 1 week. Sacrum has open decubitus that is also on base of scrotum, area swollen. Primary Diagnosis: [REDACTED]. Local infection over the buttocks Leukocytosis- acute [MEDICAL CONDITION]- Etiology ? Sepsis Decubitus Ulcer any site Drug Orders: [MEDICATION NAME] Injection 1000 mg (milligrams) IV (intravenous) once. [MEDICATION NAME]-Tazobactam Injection ([MEDICATION NAME]) 4.5 IV once. Normal saline 1000 ml (milliliters) IV [MEDICATION NAME]/Continuous. GI Cocktail 50 ml once. Potassium Chloride Oral (KDur) by mouth once. Labs: CBC (Complete Blood Count) with Differential, automated: 4/10/11 WBC: 50.5 K/ul (NL (normal limits)= 4.0-11.0) *H/H* RBC: 1.91 M/ul (NL = 4.30-5.70) *L* Hemoglobin: 5.6 g/dl (NL= 13.7-16.5) *LL* Hematocrit: 17.4% (NL= 40.0-50.0)*LL* Platelet Count: 653 K/ul (NL= 150-400) *H* [DIAGNOSES REDACTED]s, automated: 91% (NL= 45-75)*H* Monocyte, automated: 2% (NL= 3-11)*L* History & Physical...: Resident #6; [AGE] year old male was admitted for evaluation and therapy of extreme leukocytosis with 50,000 associated with hemoglobin of 5.6 and multiple draining wounds in the sacral area with foul-smelling discharge. Overall Diagnoses: [REDACTED]. Multiple sacral wounds. Profound [MEDICAL CONDITION]. status [REDACTED]. Hospital Inpatient Wound Care Consultation dated 4/13/11...: Resident #6 most recently begin to experience fevers, chills and sweats with increased drainage and malodor, and went to the emergency department on 4/10/11. He was subsequently admitted with the primary [DIAGNOSES REDACTED]. The client was started on multiple antibiotics and was evaluated by surgery yesterday, who took him to surgery and did a surgical wound debridement to his sacroperineal area of necrotic tissue with exposed bone. On 4/10/11, the wound culture showed islet beta [DIAGNOSES REDACTED] group G Streptococcus, light Proteus Mirabilis, light Morganella, and light growth of nonlactose fermenter isolated. On 4/11/11, the right distal ischial wound preliminary showed beta [DIAGNOSES REDACTED] group G Streptococcus, Proteus Mirabilis, Morganella Morganii and nonlactose fermenter isolated. The right inferior pubic ramus wound culture on 4/12/11 showed beta [DIAGNOSES REDACTED] group G Streptococcus and Morganella Morganii. Diagnostic Studies: On April 12, 2011, the Cat Scan of the pelvis with contrast showed left lower quadrant ostomy, right lower quadrant suprapubic Foley catheter, and sacral bilateral gluteal and bilateral ischial decubitus ulcers with wounds extending to the posterior cortical surface of the sacrum with [MEDICAL CONDITION], suggesting chronic osteitis and unable to exclude osteo[DIAGNOSES REDACTED] based on the views seen. Impression: 1.) [DIAGNOSES REDACTED] at the gluteal perineal area. 2.) Multiple pressures ulcers. 3.) History of T12 [MEDICAL CONDITION] and Hypertension. Operative Report: 4/11/2011. Preoperative Diagnosis; Scrotal and sacral decubitus ulcer with extension into the inferior pubic rami. Postoperative Diagnosis; Scrotal and sacral decubitus with extension into the inferior pubic rami, status [REDACTED]. Procedure in Detail...: Resident #6, a [AGE] year old T12 [MEDICAL CONDITION] male who was admitted to the hospital due to his leukocytosis,[MEDICAL CONDITION] and decubitus ulcers. General surgery was consulted for Incision and Drainage and debridement of his ulcers. The scrotum was examined and he was noted to have active drainage from a large necrotic bed. This abscess and necrotic bed was sharply excised with a large amount of purulent fluids drained and debridement was taken down to remove the entire necrotic base to bleeding tissue. The necrotic tract to the inferior pubic rami was explored and a bone biopsy was taken. This wound after a sharp debridement was irrigated with the pulse lavage with 3 liters of antibiotics solution, triple antibiotic solution. Once completed, a packing was placed into the scrotum, perineum and into the draining sinus and a dry dressing was placed over this. Postoperative Course: Resident #6 had a wound care consult. He would have to continue his IV antibiotics. His wound packing would be removed in 24 to 48 hours and he will have continued wound care with evaluation for possible secondary debridement if needed. Cat Scan of Pelvis with Contrast...: 4/12/11: Clinical history; Decubitus ulcer. At the lower abdomen there is evidence of a small amount of perihepatic ascites. There was a left lower quadrant ostomy. There was a right suprapubic urinary bladder catheter. A retrosacral decubitus ulcer was present with soft tissue thickening extending to the posterior cortical surface of the sacrum. [MEDICAL CONDITION] suggests chronic osteitis; cannot exclude osteo[DIAGNOSES REDACTED] based on these views. There were bilateral gluteal decubitus ulcers extending to the hip region bilaterally. There were bilateral ischial decubitus ulcers with evidence of bone erosion and destruction on the right. Note that gas was seen eroding into the scrotum with enlarged scrotum. Conclusion: Left lower quadrant ostomy; right lower quadrant suprapubic Foley catheter. Sacral, bilateral gluteal and bilateral ischial decubitus ulcers as described above in detail. Review of the Braden Scale- for predicting pressure sore risk dated 1/27/11 and performed by S16LPN, the following was revealed; Activity and mobility categories were checked off with a total score of (2). A score of (2) indicated that Resident #6 was at severe risk for obtaining pressure ulcers according to the Braden Scale. The Nursing Evaluation/ Pressure Sore Risk Evaluation/Skin Evaluation dated 4/04/11 performed by S16LPN the following was revealed...: Pressure ulcer to left hip has healed properly. Braden Scale total score was (17) indicating Resident # 6 was at a mild risk for obtaining pressure sores. The facility Policy/Procedure titled Wound prevention/ Skin and Wound Treatment stated the following...: Practice Guidelines: 1.) Skin integrity and risk will be initially evaluated on admission, then weekly times four (4) after admissions or readmissions, quarterly and with a significant change using the Braden Scale which addresses tissue tolerance and factors increasing exposure to pressure. ** There was no documented evidence noting the skin integrity was evaluated quarterly. 2.) All residents who score (18) or less will have a Skin Risk Evaluation and Care Plan initial upon discovery of risk or development of any pressure area. The plan of care will include: 2.1 Interventions are based on the wound, resident's medical condition, resident's mental, physical and psychosocial abilities/disabilities; they include but are not limited to: 2.1.2 If the resident is incontinent: 2.1.2.1 Apply a skin protectant three to four (3-4) times a day to the affected area(s); 2.1.2.2 Apply a moisture barrier/ointment to surround skin. ** There was no documented evidence that the above two interventions were performed. 2.1.3 Position resident off of affected area(s) when possible. ** During an interview with S12CNA on 4/20/11 at 10:00 a.m., he said that he did not assist Resident #6 with turning and repositioning because he was independent in his care and a private person. 2.1.4 Up in chair if tolerated; reposition based on Braden Scale and/ or tissue tolerance document specifics time frames in plan of care interventions. ** There was no documentation indicating that Resident #6 was reposition while in his wheelchair. The last time Resident #6's Care Plan was updated for Skin Risk Evaluation and Plan of Care was 5/04/09. The interventions listed on the Care Plan contained a box to check if it applies. There were no boxes checked for any of the interventions that could have been utilized. 2.1.8 Inspect skin daily, pay particular attention to bony prominences and areas associated with medical devices. ** There was no documented evidence that Resident #6 had daily skin inspections. 2.1.9 Range-of-motion (ROM) exercises according to restorative plan and evaluation of needs. ** There was no documented evidence indicating ROM exercises were performed. 2.1.12 Measure size of pressure area and evaluate/document findings per standards of practice. 3.) All residents at risk will have skin condition checked and documented daily by the Certified Nurse's Assistant (CNA) on the CNA Flow Sheet. 3.1 The CNA will notify the nurse of positive skin checks via written memo using CNA Notes (Post-it Communication), marking on the body figure appropriately. 3.2 Turning and repositioning will be acknowledged by documentation of the CNA initials on the CNA Care Flow Record per care plan instructions. **An interview was held on with S12CNA on 4/19/11 at 10:45 a.m. He said that he worked with Resident #6 once or twice a week. He said that the resident bathed himself and he would bring him towels. He also said that he never assisted him with his bath. S12CNA said that he would change Resident #6's bed sheets after the resident pulled the sheets off his bed and placed them in the bin. He also said that prior to the resident going into the hospital he had change his sheets and did not notice any odors or drainage on them. **A second interview was held with S12CNA on 4/20/11 at 10:00 a.m. He said that he did not inspect resident #6 skin at any time because he was a very private person. He also said that he did not assist him with turning and repositioning. 5.) All residents will have skin checks completed weekly and documented on the weekly Skin Condition Evaluation form. This form will be kept in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Skin integrity, color, moisture, temperature and turgor will be addressed. 9.) 9.1 Inspect skin daily especially over bony prominences and sites that may have impaired circulation due to positioning or from use of medical devices. ** There was no documented evidence stated daily skin inspection was conducted. 9.14 A resident should be taught/ reminded to shift his/her weight approximately every fifteen (15) minutes while in a chair. ** There was no documented evidence that the resident was reminded to shift his weight every 15 minutes. Review of the facility Weekly Skin Condition Evaluation revealed the following documentation: 1/25/11: No skin issues noted. S16LPN 2/01/11: No skin issues noted. S16LPN 2/08/11: No skin issues noted. S16LPN 2/15/11: No skin issues noted. S16LPN 2/22/11: No skin issues noted. S16LPN 3/01/11: No skin issues noted. S16LPN 3/08/11: No skin issues noted. S16LPN 3/15/11: No skin issues noted. S16LPN 3/22/11: No skin issues noted. S16LPN 3/29/11: No skin issues noted. S16LPN 4/05/11: No skin issues noted. S16LPN ** Resident #6 was admitted to a local medical center with a Stage IV sacral decubitus ulcer. Review of facility monthly summary for the month of February, 2011 and March, 2011 stated that the resident's skin status was good for both months. An interview was held with S16LPN on 4/19/11 at 3:35 p.m. She said she started working at the facility in January, 2011. She also said that she became Resident #6's nurse at the end of January for the 2 p.m. to 10 p.m. shift. S16LPN said that during her one day orientation with former LPN, she was told that Resident #6 was a private person. She said she was also told not to worry about assessing his skin because he may not let you and this was ongoing. She also said that she was told to ask Resident #6 if he had any skin issues and to document whatever he said on the weekly skin condition evaluation form. S16LPN said that she was aware that resident #6 was paralyzed from the waist down and had no feelings or sensation from the waist down. She said that she was only doing what she was oriented to do. She also said that she did not inspect or assess Resident #6's skin front or back. S16LPN said that once or twice she would ask resident #6 to assess him, but he would refuse. She also said that she did not report any of the refusals to the Charge Nurse, DON nor the resident's Physician. During an interview with Resident #6 on 4/19/11 at 10:20 a.m., he said that S16LPN became his nurse in January of this year. He also said that weekly she would come into his room and ask him if he had any skin issues and he would say "no". He said that he does not recall how many times that he may have refused, to have his skin assessed, but S16LPN stopped asking him a long time ago. Review of the MDS (Minimum Data Set) Annual assessment dated [DATE] revealed that the resident had no Pressure Ulcers as noted below: Section M150: Risk for pressure ulcers; Yes. M0210: Current Number of Unhealed Ulcers; 0. Review of the MDS Quarterly assessment dated [DATE] revealed that the resident had no Pressure Ulcers as noted below: Section M150: Risk for pressure ulcers; Yes. M0210: Current Number of Unhealed Ulcers; 0. Review of Resident # 6 Plan of Care revealed the following...: Original Date: 5/04/09 Risk Factor/Problem: Has the following skin conditions and/or wounds (describes) Stage IV Left Hip. As evidenced by: No redness, no malodor, no increased temperature, no purulent drainage. Goal: Skin will remain intact and will experience no skin breakdown through next review. Wound and/or skin Condition (specific goal): Will remain free from infection. Goal Date: 8/04/09, 11/10/09, 2/10/09, 5/10/10, 8/11/10, 11/03/10. Interventions: **There were no boxes checked indicating interventions were utilized. An interview was held with S8LPN/MDS (Minimum Data Set) on 4/21/11 at 8:10 a.m. After reviewing Resident #6's care plan she confirmed that the last time the skin assessment care plan was updated/ revised was 5/04/09 and no boxes were checked indicating that interventions were implemented or utilized. She also said that when she started working at the facility his wound had already healed and that was documented on his care plan. S8LPN said that even though the wound had healed he was still at risk for developing pressure ulcers because he was a paraplegic. She said that there should be an at risk skin care plan in place, but she was not responsible for doing this. She said that there was a care plan meeting at the end of March, 2011 and the resident's skin condition was discussed and there was no skin issues voiced at the meeting. An interview was held with S21LPN MDS on 4/21/11 at 8:20 a.m. She also confirmed that Resident #6 skin assessment care plan had not been updated since 5/04/09. She said that the nurses were responsible for the admit evaluation and the quarterly assessment. S21LPN/MDS said that the nurses would perform the Braden scale and implement the skin assessment care plan. She said that the nurses were responsible for initialing all at risk skin care plans and she was responsible for the diseases and the ADLs (activities of daily living). A second interview was held with S8LPN MDS on 4/21/11 at 8:30 a.m. She said that when she started working at the facility they had nurse consultants doing all of the skin audits. She said that she was told that she was not responsible for the skin assessments on the care plans. She also said that she was told to do the diseases and the ADLs of the care plans. During an interview with S10LPN Unit Manager on 4/21/11 at 8:35 a.m., she also confirmed that the skin assessment care plan had not been updated or revised for resident #6. She said that in the past the wound care nurse was responsible for care planning and updating all high risk residents' skin assessment and all active pressure ulcers residents. An interview was held with S1DON on 4/21/11 at 8:35 a.m. She also confirmed that resident #6's skin assessment care plan had not been updated since 5/04/09. She said that where she came from the MDS nurses were responsible for updating the skin assessment care plans. She also said that the Unit Managers were responsible for the daily up keep of all high risk pressure ulcers residents. S1DON said that she was not sure what the policy stated here, but she was accustomed to what she had mentioned above as way the skin assessments/care plans should have been handled. S1DON said that she would review the policies on skin assessment and care plans because there seemed to be a lot of confusion on what the nurses should do and she was not aware of their roles and what they should be doing. During a second interview with S1DON on 4/21/11 at 9:20 a.m., she said that she must apologize for thinking the MDS nurses was responsible for the skin assessment care plan; "I was wrong." She also said that she has been a nurse for over [AGE] years and it was always done this way. She also said that she does not know what the nurse's roles were and who should be responsible for what duties. Review of the facility internal investigation dated 4/11/11 titled ANEMI revealed the following...: Date initiated: 4/11/11. Date of Incident: 4/10/11 at 12:35 p.m. Date of Incident Identified: 4/10/11 at 12:35 p.m. Location of Incident: Resident #6. Type of Incident: Neglect. Recent Unexplained Injury (Specify): Wound to sacrum. Mobility status at time of incident: wheelchair. Does the care plan establish the presence of or risk for the injury? Yes. If yes, describe: At risk for skin breakdown- 5/04/09. Stage IV Left Hip (Limited mobility, Paraplegic, History of Pressure ulcer. Alleged Perpetrator: S16LPN. Notification Information: Attending Physician: Facility Nurse Practitioner on 4/10/11 at 2:20 p.m. Responsible party: None per resident's request. Administrator: DON notified. Results of incident: Did injury occur?: Yes; wound to sacrum. Was treatment provided? Yes-off-site. Transferred to hospital? Yes. Summary of Incidental/Allegation: On 4/10/11 a wound was found to resident #6's sacrum. The resident was sent to the hospital on [DATE]. Skin condition evaluation sheet was done on 4/05/11 during the 2 p.m. to 10 p.m. shift by S16LPN. She charted that resident #6 had no skin issues noted at this time. Did Description of allegation remain consistent? No. If alleged perpetrator is named, does he/she deny allegation? No. Does alleged perpetrator have a history of similar complaints? No. If alleged perpetrator is an employee, has he/she completed the accursed employee statement? Yes. Accursed Employee's Statement: Resident #6 was my weekly body audit on the 2 p.m.-10 p.m. shift. During orientation with another LPN I was told after leaving the resident room not to do his body audits because he will not let you and he was in his right mind. She also states that she put no skin issues noted because that was what she was taught to do and what have gone on previously. Resident #4 Resident #4 was an [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. The most recent Minimal Data Set ((MDS) dated [DATE] in Section C0500 revealed the resident ' s cognitive status summary score to be a 3; Severe impairment. Review of the MDS Quarterly assessment dated [DATE] revealed that the resident had no Pressure Ulcers as noted below: Section M150: Risk for Pressure Ulcers. 1 Yes M0300: Current Number of Unhealed Pressure Ulcers. 0 Review of the MDS Quarterly assessment dated [DATE] revealed that the resident had no Pressure Ulcers as noted below: Section M0150: Risk of Pressure Ulcers 1. Yes M0300: Current Number of Unhealed Pressure Ulcers 0 Review of the April 2011 Physician order [REDACTED]. 12/16/10 Protective Moisture Barrier Cream-apply to buttocks with every brief

Based on record review and interview the facility failed to ensure that the Director of Nurses (DON) directed nursing care and services by failing to clinically supervise the provision of nursing care to ensure nurses accurately and consistently conducted weekly body audits for 2 of 6 residents reviewed for pressure ulcers. (#6, #4) The facility's DON failed to ensure policies/ procedures and a system of clinical supervision were implemented to ensure that residents admitted to the facility were assessed weekly and did not develop pressure ulcers in the facility. Resident #6 was placed in an Immediate Jeopardy situation on 1/25/11 when the staff failed to perform the resident's weekly body audits to detect the development of a pressure ulcer which resulted in Stage IV bilateral sacral/gluteal pressure ulcer and bilateral ischial ulcer with wounds extending to the posterior cortical surface of the scrotum with [MEDICAL CONDITION]. This required hospitalization with extensive surgical debridement down to the bone of the sacral wound for Resident #6. The Administrator was notified of the Immediate Jeopardy situation on 4/19/11 at 4:07 p.m. The Immediate Jeopardy was removed on 4/10/11 at 2:40 p.m. when he resident was transferred to the hospital. Resident #4 was placed in an Immediate Jeopardy situation on 4/4/11 when the staff failed to perform the residents weekly body audit to detect the development of a pressure ulcer which resulted in Stage IV decubitus to his right heel with bone exposed. The Administrator was notified of the Immediate Jeopardy situation on 4/19/11 at 4:07 p.m. The Immediate Jeopardy was removed on 4/19/11 at 12:47 p.m. when the resident was transferred to the hospital. The deficient practice will continue as a level II with the potential for more than minimal harm for the 38 residents determined to be at high risk for development of pressure ulcers. Findings: Resident #6 Resident #6 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His cognitive level was a total of 15 points indicating cognitively intact. Resident #4 Resident #4 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. Most recent Minimal Data Set ((MDS) dated [DATE] in Section C0500 revealed the resident's cognitive status summary score to be a 3; Severe impairment. Cross reference Tags 281 and 314.

Based on observations, interviews, record review, and policy review, the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents with pressure ulcers (#4, #6) by failing to: 1) Ensure that a resident who entered the facility with a Stage IV pressure ulcer that had healed did not develop another pressure ulcer in the facility; (#6). 2)Ensure that a resident who entered the facility without a pressure ulcer did not develop a Stage IV pressure ulcer; (#4). 3) Supervise staff to ensure weekly skin assessments were completed timely and accurately; (#6, #4) and 4) Have a system in place to ensure Certified Nursing Assistants (CNA's) were reporting skin changes observed during bathing and turning of residents and reporting those findings to the nurses. (#6, #4) The facility's administration failed to develop and implement policies and procedures and a system of clinical supervision to ensure a resident admitted to the facility with a Stage IV pressure ulcer that had healed did not develop a Stage IV pressure ulcer in the facility. Resident #6 was placed in an Immediate Jeopardy situation on 1/25/11 when the staff failed to perform the residents' weekly body audits to detect the development of a pressure ulcer which resulted in Stage IV bilateral sacral/gluteal pressure ulcer and bilateral ischial ulcer with wounds extending to the posterior cortical surface of the scrotum with [MEDICAL CONDITION]. This required hospitalization with extensive surgical debridement down to the bone of the sacral wound for Resident #6. The Administrator was notified of the Immediate Jeopardy situation on 4/19/11 at 4:07 p.m. The Immediate Jeopardy was removed on 4/10/11 at 2:40 p.m. when the resident was transferred to the hospital. Resident #4 was placed in an Immediate Jeopardy situation on 4/4/11 when the staff failed to perform the residents' weekly body audit to detect the development of a pressure ulcer which resulted in Stage IV decubitus to his right heel with bone exposed. The Administrator was notified of the Immediate Jeopardy situation on 4/19/11 at 4:07 p.m. The Immediate Jeopardy was removed on 4/19/11 at 12:47 p.m. when the resident was transferred to the hospital. The deficient practice will continue as a level II with the potential for more than minimal harm for the 38 residents determined to be at high risk for development of pressure ulcers.. Findings: Resident #6 Resident #6 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His cognitive level was a total of 15 points indicating cognitively intact. Resident #4 Resident #4 was an [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. Most recent Minimal Data Set ((MDS) dated [DATE] in Section C0500 revealed the resident ' s cognitive status summary score to be a 3; Severe impairment. Cross reference Tags 281 and 314.

Based on observations, clinical record reviews, and interviews, the facility failed to ensure that: 1. A resident identified as having a small skin break to the buttocks was assessed by a nurse to identify the appropriate care needed to the area prior to it resulting in a Stage III pressure ulcer for 1 of 9 sampled residents identified as being at high risk for the development of pressure ulcers. (#12) 2. A change in the resident's skin condition was identified through assessment prior to it progressing to a Stage IV pressure ulcer for 1 of 9 sampled residents identified as being at high risk for the development of pressure ulcers (#20). 3. The RN and/or Wound Care Nurse were made aware of changes in the resident's skin condition in order to provide a follow-up assessment to identify the appropriate care needed for 1 of 9 sampled residents identifed as being at high risk for the development of pressure ulcers (#12). Resident #12 On 11/10/10, S21LPN became aware that Resident #12 had a small skin break noted to the left lower buttocks. In the nurses' notes it was noted that the area was slightly reddened with slight pus drainage noted to the area. Review of the record revealed there was no assessment of the area after it was identified by S21LPN, prior to S10RN Wound Care Nurse being made aware of the open area on 11/15/10 by the surveyors. The facility failed to assess the area to identify the appropriate care needed for the resident's wound. This resulted in actual harm to Resident #12 when an area identified as a small skin break on 11/10/10 resulted in a Stage III pressure ulcer (as identified by S10RN Wound Care Nurse on 11/15/10.) Resident #20 Upon reviewing the resident's clinical record, it was revealed that the resident had "no skin interruptions" on 8/7/10 and 8/14/10. It also revealed that on 8/20/10 it was documented that the resident had a Stage IV pressure ulcer. The facility failed to identify, through assessment, a change in the resident's skin condition. This resulted in actual harm to the resident when the facility was unaware of her wound until it was a Stage IV pressure ulcer. Findings: Resident #12 Resident #12 was initially admitted to the facility on [DATE] and her last re-admitted to the facility was on 10/15/10. The resident ' s [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that her cognitive skills were severely impaired, and she was totally dependent on one person for physical assistance for bed mobility, eating, and toileting. The resident was incontinent of bowel and bladder. The resident was assessed to not have a pressure ulcer on admission. The resident was assessed to be at risk for the development of a pressure ulcer and at the time of the assessment on 11/16/10 had developed one stage III pressure ulcer after her admission on 10/15/10. The pressure ulcer dimensions were recorded as 1.3 cm X 1.0 cm X .1 cm with slough on the MDS dated [DATE]. Resident #12 ' s skin audit was conducted with S17LPN on 11/15/10 at 2:50 p.m. An assessment of the left buttock fold at the top of her left leg revealed an open wound assessed by S17LPN, to be as long as her pinky finger. An interview was held on 11/15/2010 at 3:00 p.m. with S17LPN. S17LPN stated that she was the nurse assigned to care for Resident #12 for the current shift. S17LPN stated that she had no prior knowledge of the pressure ulcer to Resident 12 ' s left buttock. An observation of a skin assessment was conducted on 11/15/2010 at 3:05 p.m. with S10RN Wound Care Nurse. She assessed the wound as a Stage III pressure ulcer to the upper left leg at the left fold between the lower buttocks. She stated she was not aware of the Stage III pressure ulcer prior to the skin assessment today. Review of the Nurse/Physician Communication Record dated 11/15/2010 at 3:15 p.m. stated that S10RN Wound Care Nurse was summoned to assess an area of concern on (L) upper leg in fold. Upon assessment she noted a Stage III pressure ulcer measuring 1.3 X 1cm X 0.1 wound bed that was yellow with slough present. Periwound was assessed to be red. New orders were noted. No odor was detected. She summoned the doctor to assess the area and received new orders to clean the wound with wound cleaner and dry. Further instructions were to apply Santyl ointment to the wound bed and cover with [MEDICATION NAME] dressing and change every 3 days. She was awaiting a call back from the family. She noted plans to continue to monitor and follow through with orders as ordered. An interview was held with S13CNA on 11/15/2010 at 3:37 p.m. regarding her observation of Resident #12's skin with incontinent care. She stated she thought that she first observed the wound being open on 11/14/2010. Previously, she stated, before the wound opened up, it was just a reddened area, she had applied an antiseptic cream to the area while performing incontinence care. She stated that she assumed that the wound had been reported to the nurse already. She stated she had not reported the pressure ulcer to anyone or documented the pressure ulcer in the CNA Notes, or had the resident's nurse sign any documentation of the pressure ulcer. An interview was held with S12LPN Charge Nurse for hall "B" and S10RN Wound Care Nurse on 11/15/2010 at 3:43 p.m. S12LPN Charge Nurse stated that the pressure ulcer was first discovered on 11/10/2010. S12LPN Charge Nurse stated that the night shift nurse discovered the ulcer and called the doctor and reported her findings and actions to her the morning of 11/11/2010. S12LPN Charge Nurse for hall "B" stated she talked about the findings in the morning report and reported the ulcer on the morning of 11/11/2010 to the S10RN Wound Care Nurse. S10RN Wound Care Nurse stated she was not informed in morning report of the change in Resident #12's skin. S10RN Wound Care Nurse stated that she should have been notified on the morning of 11/11/2010 when the wound was assessed to have worsened on the evening of 11/10/2010. Another interview was held with S10RN Wound Care Nurse on 11/16/2010 at 12:56 p.m. She stated that the wound was assessed as a Stage I on 10/27/2010 and was only a reddened area. She further stated that the last time she assessed the area it was only red without any broken area. She was unable to provide any documentation of the wound being assessed as a Stage I pressure ulcer or any treatment being performed on the wound prior to 11/15/10, when the observed body audit was performed with S17LPN. She stated that she was only aware of a reddened area to the left upper leg in the fold of the buttock area. She was not aware the resident had an open wound. She also stated she did not start a treatment MAR for 11/11/10, because she was not made aware of the wound. An interview was held with S7DON on 11/16/10 at 1:00 p.m. She stated the reddened areas assessed on the Nursing Evaluation dated 10/28/2010 should have been marked and measured and documented on the Nursing Evaluation form. An interview was held 11/18/10 at 10:20 a.m. with S12 LPN Charge Nurse for Hall "B". She stated that the Wound Care Nurse does the Skin Risk Evaluation and Plan of Care when a resident is assessed as at risk for pressure sores. An interview was held with S25LPN on 11/18/10 at 10:40 a.m. She stated she was the Wound Care Nurse when Resident #12 was readmitted to the facility on [DATE]. After S25LPN reviewed the resident's clinical record, she verified that there was not a Skin Risk Evaluation or Plan of Care done, or documentation that Resident #12 was assessed as being at risk for pressure sores on the 10/15/10 or 10/28/10 Nursing Evaluation Forms. Resident #12 clinical record review revealed the following on the Nursing Evaluation Forms: 10/15/10 on readmission revealed no documented abnormalities of the skin related to pressure areas. The Braden Scale for Prediction Pressure Sore Risk was completed with a total score of 15. A score of 18 or below indicated the resident was at risk for developing a pressure sore. For a risk score less than 18 directions were to complete the skin risk assessment evaluation and initiate the problem on the care plan. 10/28/10 revealed the Braden Scale for Prediction Pressure Sore Risk was completed with a total score of 14. A total score of 18 or below indicated the resident was at risk for developing a pressure sore. For at risk scores less than 18; directions on the Nursing Evaluation form stated to complete the Skin Risk Evaluation and initiate the problem on the care plan. 10/28/2010, under the section labeled Pressure Sore Evaluation/Skin Evaluation, revealed an entry by S10RN Wound Care Nurse. The entry revealed upon assessment, red blanchable areas noted on buttocks. Directions under this section were to provide descriptions and measurements for all abnormalities. There were no measurements for the identified abnormalities. Review of Weekly Skin Condition Evaluation for the month of November 2010 revealed an entry dated 11/4/2010. The entry stated BIL (bilateral) AKA (above knee [MEDICAL CONDITION]) with no other findings. Another entry dated 11/11/2010 revealed under the comments section, see treatment MAR. Review of the record revealed no treatment MAR for 11/11/2010. Review of the Case Mix ADL Flow Record revealed no documented CNA skin checks on 11/4/2010, 11/5/2010, 11/7/2010, 11/8/2010, and 11/10/2010 through 11/17/2010. A review of Resident #12 ' s Nurses Note revealed the following: 11/10/2010 at 6:30 p.m. by S21LPN stated, client has a small skin break noted to the left lower buttocks. Slight reddened with slight pus drainage noted to the area. She called the doctor and was awaiting a call back. 11/10/2010 at 7:40 p.m. stated that S21LPN received new orders for the resident from the doctor's office. 11/10/2010 at 10:30 p.m. stated that S21LPN received, noted, and carried out an order to discontinue Keflex and start Bactrim DS twice a day for seven days for open area to buttock draining pus. Review of a memo in the CNA Communication Book revealed CNAs are to report all findings with residents in their care; in writing on a CNA Communication Sheet and orally to that resident's nurse. The CNAs are to report any skin issues such as rashes, bruises, any and all skin tears and other open areas on the resident's skin. An interview was held with S9CNA Supervisor on 11/15/2010 at 3:41 p.m. regarding the procedure for CNAs to follow when a change in skin integrity was observed. She stated that any change in the integrity of a resident's skin was to be reported by the CNA to the resident's nurse as soon as observed. She also stated she should fill out a paper in the CNA Notes and have the nurse sign the note indicating she had been informed of the skin wound. S9CNA Supervisor stated that the resident's nurse would then report the development of a pressure ulcer to the Wound Care Nurse. She further stated the CNAs were in-serviced recently on reporting all findings orally to the resident's nurse and in writing on the CNA Communication sheet. The S9CNA Supervisor on 11/15/10 at 3:45 p.m. stated she did not remember the date of the training for CNAs related to the memo in the CNA Communication Log. The in-service instructed the CNAs to report all skin issues to the residents' nurses. The facility failed to ensure that an RN and/or Wound Care Nurse were made aware of changes in the resident's skin condition and that the resident was assessed by an RN and/or Wound Care nurse to identify the apporpriate care needed to a skin break with redness and drainage of pus. This resulted in harm to the resident when the area was left untreated, and she developed a Stage III pressure ulcer. Resident #20 Resident # 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] revealed the resident's cognitive status was severely impaired. She was totally dependent on staff for all of her care including transfers, position changes, incontinent care and Activities of Daily Living. Review of the record revealed a Skin Risk Evaluation and Plan of Care dated 07/20/10 with a Braden Scale Score of 14. A Braden Scale Score of 18 or below indicated at Risk for Skin breakdown. For a risk score less than 18 the directions were to complete the skin risk assessment evaluation and initiate the problem on the care plan. A review was done of the Nursing Evaluation dated 07/20/10, when the resident was admitted to the facility. It revealed the resident required assist of two staff for transfers, bed mobility, and toileting. The Braden Scale on the Nursing evaluation revealed a score of 14 which indicated the resident was At Risk for developing a pressure sore. The Skin Evaluation on the back of the form revealed the following: "dry scaly skin to heels & feet, end of toes c (with) dry scaly skin. Small scratch to (R) groin. No other breakdown or pressure areas noted." Review of the Nurses Notes dated 08/20/10 and signed by S10RN Wound Care Nurse revealed "Resident found c (with) wound to (R) malleolus; yellow tissue serosangeous drainage painful to touch; ______NP (Nurse Practitioner) notified of new wound. Resident is [MEDICAL CONDITION] (R) hemi paresis. New orders for Santyl & dry dressing daily ______for wound." There was no documentation in the nurses note to indicate who informed the Wound Care Nurse of the wound to the resident right outer ankle. Review of the Weekly Skin Condition Evaluation form revealed documentation on 08/07/10 and 08/14/10 of "O (no) skin interruptions noted". On 08/21/10 documentation revealed on the form revealed "(R) outer ankle area noted c (with) pressure ulcer found on 08/20/10." Review of the Wound Treatment Evaluation Record dated 08/20/10 revealed documentation of a Stage III with IV written over it that measured 1 x 0.8 x 0.1 with yellow wound bed, intact edges and dry. Review of the Physician Patient Note dated 07/26/10 revealed no problems with her skin. On 08/23/10 the physician documented under the skin area on the Patient Note "III-IV decubitus (R) heel." Review of the Care Plan revealed a Risk Factor/Problem dated 07/20/10 of "At Risk for skin breakdown related [MEDICAL CONDITION], A. Fib ([MEDICAL CONDITION] Fibrillation), DM (Diabetes Mellitus), Right [MEDICAL CONDITION], Depression [MEDICAL CONDITION](Hypertension)." Interventions under B. Mobility/Activity Deficit for Bed-bound Residents included use pillows to protect bony prominences; use pillows or devices that relieve pressure on heels; avoid positioning directly on hips; use lifting devices, turn sheets to reposition or transfer; reposition q (every) 2 h (hours) or PRN (as needed). and Screen by PT/OT (Physical Therapy/Occupational Therapy) for rehab potential. Review of the Physician order [REDACTED]. Review of the Physician Telephone Orders revealed an order dated 08/23/10 to "Apply Prevalon Boot to (R) leg & float both feet on pillows while in bed." On 11/17/10 at 1:30 p.m. an interview was held with S10RN Wound Care Nurse. She reported she had been employed at the facility for the past 2 weeks and didn't see the wound when it first developed. She said since she had been treating the wound it had improved. On 11/17/10 at 1:40 p.m. an interview was held with S34CNA Treatment Tech working with the wound care nurse. She reported she had been working at the facility for over a year as a Treatment Tech. She revealed the resident was admitted with no pressure wounds. She said the resident was a right [MEDICAL CONDITION] and slept with her right leg turned outward with the right ankle resting on the mattress. She reported the resident developed a small pressure ulcer on the outside of her right ankle. She said when it was found it was the size of a pencil eraser with yellow slough covering the wound bed. She reported the nurse received an order for [REDACTED]. On 11/17/10 at 2:00 p.m. an observation was made of the resident lying in bed with her right leg turned outward and the Prevalon boot in place. An observation was made of the pressure ulcer on the resident's right outer ankle with S10RN Wound Care Nurse and S34CNA Treatment Tech. The Prevalon Boot was removed from the right lower leg. The nurse removed the dressing from the wound. The wound bed was about 1 centimeter in diameter and was bright pink with blood tinged drainage. She reported she had just completed wound care before the observation by cleaning the wound with wound cleanser and applying [MEDICATION NAME] ointment to the wound. After the observation she recovered the wound with a dressing. The Prevalon boot was reapplied. During the wound care no low air loss mattress overlay was observed on the resident's bed. Review of the Wound Treatment Evaluation Record dated 08/20/10 and 08/27/10 revealed the pressure ulcer was staged as a Stage IV. On 11/12/10 documentation revealed a Stage III to the right malleolus round, 1.4 x 1.3 x 0.1 cm. red with macerated ulcer edges and moderate sersangeous drainage. On 11/17/10 at 2:10 p.m. an interview with S28LPN who worked with the resident on the morning shift, revealed the resident was unable to tell them when something was wrong. She said when the resident was in bed her right leg was paralyzed from the stroke and turned outward with the right ankle against the mattress. She reported she didn't work with the resident when the pressure ulcer was found in August. She said the resident currently had a boot to the right leg/foot to prevent pressure on the right outer ankle area. She said she had to be turned by staff because she was unable to turn herself. On 11/17/10 at 2:40 p.m. an interview was held with S8ADON. She reported the resident was admitted with no wounds and skin intact. She said she developed a pressure ulcer to her right outer ankle because when she was in bed her right leg turned out resulting in pressure on the right outer ankle. She reported all of the beds in the facility had pressure relieving mattresses. She said if a pressure area developed then a low air loss mattress would be placed on the bed. She said she didn't know why the resident didn't have one placed on her bed after she developed the pressure ulcer. She reported when the CNAs provided daily care for the residents they assessed the residents' skin and would report any changes to the nurse. She said the staff nurses did weekly skin assessments on all of the residents. She reported she didn't know why the resident's pressure ulcer was not found until it was a Stage III-IV. On 11/17/10 at 2:55 p.m. an interview with S29LPN Charge Nurse on "A" Hall where the resident resided. She reported when the resident was admitted she had dry skin but did not have any skin breakdowns. She said the resident's room was across from the nurses' station and the door to the room stayed open for observation. She reported the resident stayed in bed a lot when she was first admitted to the facility and couldn't talk. The Charge Nurse reported all residents had pressure relieving mattresses on their bed. She reported she didn't remember the resident ever having a low air loss overlay mattress on her bed because her pressure ulcer wasn't on her sacrum it was on her right ankle. She said a boot was ordered for the resident after the pressure ulcer was found and her foot was elevated. She reported when the resident was positioned on her right side she could still move enough so that her right leg was turned out with the boot lying on the mattress. On 11/17/10 at 3:00 p.m. an interview with S30CNA evening shift and revealed she had worked at the facility for 2 months. She said the resident had the pressure ulcer on her right ankle when she started working with her. On 11/18/10 at 9:45 a.m. an interview was held with S32CNA who had worked at the facility for 1 ? years on the day shift. She reported the resident had the boot on her right foot because of the pressure ulcer when she started taking care of her. She said the resident could use her left leg to move her right leg when she was in the bed. On 11/18/10 at 10:50 a.m. another interview was held with S29LPN Charge Nurse on "A" Hall. She reported she was the charge nurse on the hall when the pressure ulcer was found on the resident. She said the wound care nurse who documented the wound assessment on 08/20/10 no longer worked at the facility. She reported she didn't know if someone told the wound care nurse about the wound or if she found it herself. She said the wound care nurses didn't routinely do skin assessments on the residents so someone must have told her. She reported sometimes the wound care nurses did do skin assessments of the whole facility, but she couldn't say for sure if that was how the wound care nurse had found the wound. She reviewed the Nurse's Notes for 08/19/10, 08/20/10, and 08/21/10. She reported the wound care nurse documented the wound and that she notified the physician. She said orders were received for wound care and the boot. She reviewed the 24 hour nurse jot sheet for August 19th, 20th ,and 21st and didn't find any documentation that indicated who found the resident's pressure ulcer on 08/20/10. The facility failed to ensure that a resident admitted to the facility with no skin breakdown and who was At Risk for skin breakdown didn't develop a pressure ulcer. The resident was found with a Stage III-IV pressure ulcer on her right outer ankle 6 days after she was assessed with [REDACTED]. " The facility failed to identify, through assessment, a change in the resident's skin condition prior to it progressing to a Stage IV pressure ulcer.

Based on interview, observation, and record review, the facility failed to: 1. update the care plan on 11/15/10 to address blanchable red areas to both heels discovered on 11/15/10 (#15); 2. care plan new interventions addressing the resident's noncompliance with heel protectors after the facility was aware of the noncompliance (#15); 3. ensure the treatment nurse documented an assessment conducted on 11/15/10. The assessment was of the blanchable red areas to both heels (#15); 4. assess the blanchable red areas to both heels for changes after discovery on 11/15/10 (#15); 5. for a resident at high risk for pressure sore development, assess the resident's skin and discover a new pressure sore to the left heel before it reached stage II severity (#16); 6. ensure CNAs notified nursing of changes in a resident's skin (#12); 7. care plan the resident for being at risk for pressure sore development (#12); 8. comprehensively assess a red blanchable area discovered on the resident's buttocks on 10/28/10 (#12); 9. notify the wound care nurse on 10/28/10 when a a red blanchable area was discovered on the resident's buttocks (#12); 10. update the care plan to address assessment and care to new areas to the heels when discovered (#15); 11. notify the wound care nurse and begin routine assessments and treatment to the area when a a small skin break slightly red with slight pus drainage was found on 11/10/10 by a floor nurse (#12); 12. ensure the LPN comprehensively assessed an area to the left lower buttock's fold on 11/15/10 at 2:50 p.m. including measurements, color, drainage, odor if present (#12); 13. document on the 24 hour communication book regarding changes to the resident's skin for the dates of 11/10/10 and 11/11/10 (#12); 14. ensure the caloric and protein needs were maintained for a resident at risk for developing a pressure ulcer. The facility failed to refer to the dietician when a change was made on 11/2/10 to the resident's enteral feeding (#12); 15. prevent pressure to a resident's right outer ankle (#20); and 16. assess and discover a pressure sore before it reached stage III/IV severity (#20). The extent of this deficient practice is 4 of 9 residents at risk for pressure sores out of a total of 24 sampled residents. Resident #12 experienced actual harm when an area identified as a small skin break on 11/10/10 progressed in severity to a Stage III pressure ulcer. Resident #20 was admitted to the facility with a [DIAGNOSES REDACTED]. The facility failed to relieve pressure to the resident's right outer ankle. The resident experienced actual harm when the facility failed to discover a pressure sore to the resident's right outer ankle before it reached Stage III/IV severity. Findings: Review of the facility's policy for Wound Prevention/Skin and Wound Treatment under the heading of Standards revealed in part.."Residents will exhibit no evidence of skin breakdown or will regain skin integrity if evaluated with wounds unless it is determined that this is not a reasonable outcome due to certain factors, i.e. multi-system factors, end of life condition, or refusal of treatment. Residents will receive appropriate interventions to stabilize or lessen their wound stage during their stay and be monitored for pain, trauma, and infection in all area of resident care...Nursing staff will have an understanding of the protocols for maintaining skin integrity, initiating interventions to provide appropriate care based on the type of wound, and documentation of standards according to protocol." Policy and Procedure Wound Prevention/Skin and Wound Treatment Practice Guidelines 1. Skin integrity and risk will be initially evaluated on admission, then weekly times four after admission or readmission, quarterly, and with a significant change using the Braden Scale, which addresses tissue tolerance and factors increasing exposure to pressure. 2. All residents who score eighteen (18) or less will have a Skin Risk Evaluation and Care Plan initiated upon discovery of risk or development of any pressure area. The plan of care will include: 2.1.8 Inspect skin daily, pay particular attention to bony prominences and areas associated with medical devices........... 3. All residents at risk will have skin condition checked and documented daily by the Certified Nursing Assistant on the CNA Care Flow Record. 3.1 The CNA will notify the nurse of positive skin checks via written memo using the CNA Notes (Post-It Communication), marking on the body figure appropriately. 4. The nurse will review, evaluate, document, obtain appropriate treatment orders as indicated, and respond to information from the CNA. 7. All wounds will be evaluated upon discovery and weekly and documented on the Wound Treatment and Evaluation Record. Admitting nurses will complete all aspects of the evaluation with the exception of staging, which will be performed by the wound nurse or designee within twenty-four hours. A separate form is to be used for each wound. 8. A weekly wound report, Weekly Wound/Skin abnormality Tracking Log, will be completed by the wound nurse or designee and a copy given to the Director of Nurses (DON), Administrator, MDS Coordinator, Registered Dietician/Registered Dietary Tech, and Unit Managers. 9. The following preventive standards for mobility/activity/sensory deficits should be initiated and documented on the plan of care when appropriate. 9.1 Inspect skin daily, especially over bony prominences and sites that may have impaired circulation due to positioning or from use of medical devices. 9.2 Reposition as often as needed based on skin integrity after pressure have been reduced or redistributed. 9.8 Use pillows/positioning orthotics for pressure relief on all bony prominences. 9.9 Use heel protectors and/or pillows to keep heels off of bed (floating of heels). 9.12 Apply pressure reducing cushions/mattress. 9.13 Use therapeutic bed/low air loss bed when indicated. 13. If skin integrity is compromised: 13.1 Document findings on Wound Treatment and Evaluation Record. 13.2 Obtain a physician order [REDACTED]. Note: Physician orders [REDACTED]. 13.3 Initiate/revise Skin/Wound Care Protocol. 13.5 Initiate/Revise Skin Risk Evaluation and Care Plan to address current skin condition. 14. Evaluate, measure, stage, and document findings on Wound Treatment and Evaluation Record. 15. Evaluate wound daily by noting exudates, pain, and wound bed characteristics, description of wound edges and surrounding tissues..... 16. A complete wound evaluation and documentation shall be done weekly on the Wound Treatment and Evaluation Record for each wound. This should include: location, staging, size..., exudate...,pain..., wound bed..., and description of wound edges and surrounding tissue...... Resident #12 Resident #12 was initially admitted to the facility on [DATE] and her last readmitted to the facility was on 10/15/2010. Her [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that her cognitive skills were severely impaired, and she was totally dependent on one person for physical assistance for her bed mobility, eating, and toileting. The resident was incontinent of bowel and bladder. She was assessed to have no pressure ulcers on the 10/15/10 admission. The resident was assessed to be at risk for the development of a pressure ulcers and at the time of the MDS dated [DATE], she had developed 1 (one) stage III pressure ulcer. The pressure ulcer dimensions were recorded as 1.3 cm. X 1.0 cm. X .1 cm. with slough on the MDS dated [DATE]. Review of the Nursing Evaluation, conducted on 10/15/2010 on re-admission to the facility, revealed no documented abnormalities of the skin related to pressure areas. The Braden Scale for Prediction Pressure Sore Risk was completed with a total score of 15. Review of the Nursing Evaluation dated 10/28/10 revealed the Braden Scale for Prediction Pressure Sore Risk was completed with a total score of 14. A score of 18 or below indicated the resident was at risk for developing a pressure sore. For a risk score less than 18; the directions on the Nursing Evaluation were to complete the skin risk assessment evaluation and initiate the problem on the care plan. Both the 10/15/10 and 10/28/10 Nursing Evaluation revealed a Braden Scale Prediction Pressure Score of less than 18. An interview was held 11/18/2010 at 10:20 a.m. with S12LPN Charge Nurse for Hall "B". She stated that the Wound Care Nurse does the Skin Risk Evaluation and Plan of Care when a resident was assessed as at risk for pressure sores. An interview was held with S25LPN on 11/18/10 at 10:40 a.m. She stated she was the Wound Care Nurse when Resident #12 was readmitted to the facility on [DATE]. After review of the resident's clinical record by S25LPN, she verified that there was not a Skin Risk Evaluation or Plan of Care done or documented when Resident #12 was assessed as being at risk for pressure sores for 10/15/10 and the 10/28/10 Nursing Evaluations. Review of the Nursing Evaluation dated 10/28/2010, under the section labeled Pressure Sore Evaluation/Skin Evaluation, revealed an entry by S10RN Wound Care Nurse. The entry revealed upon assessment, red blanchable areas noted on buttocks. Directions under this section were to provide descriptions and measurements for all abnormalities. There were no measurements for the identified abnormalities. An interview was held with S7DON on 11/16/10 at 1:00 p.m. She stated the reddened areas assessed on the Nursing Evaluation dated 10/28/2010 should have been marked and measured and documented on the Nursing Evaluation form. A skin assessment observation of Resident #12 was conducted with S17LPN on 11/15/10 at 2:50 p.m. An assessment of the left buttock fold revealed an open wound assessed by S17LPN, to be as long as her pinky finger. An interview was held on 11/15/2010 at 3:00 p.m. with S17LPN. She stated she was the nurse assigned to care for Resident #12 for the current shift. She stated that she had no prior knowledge of this ulcer. Review of Weekly Skin Condition Evaluation for the month of November 2010 revealed an entry dated 11/4/2010. The entry stated BIL (bilateral) AKA (above knee [MEDICAL CONDITION]) with no other findings. Another entry dated 11/11/2010 revealed under the comments section, see treatment MAR. Review of the Nurses Note for Resident #12 written on 11/10/2010 at 6:30 p.m. by S21LPN stated client has a small skin break noted to the left lower buttocks. Slight reddened with slight pus drainage noted to the area. She called the doctor and was awaiting a call back. Review of the Nurses Note for Resident #12 written on 11/10/2010 at 7:40 p.m. stated that S21LPN received new orders for the resident from the doctor's office. Review of the Nurses Note for Resident #12 written on 11/10/2010 at 10:30 p.m. stated that S21LPN received, noted, and carried out an order to discontinue Keflex and start Bactrim DS twice a day for seven days for open area to buttock draining pus. An interview was held with S10RN Wound Care Nurse on 11/16/2010 at 12:56 p.m. She stated that the wound was assessed as a Stage I on 10/27/2010 and was only a reddened area. She further stated that the last time she assessed the area it was only red without any broken area. She was unable to provide any documentation of the wound being assessed as a Stage I pressure ulcer or any treatment being performed on the wound prior to 11/15/10, when the observed body audit was performed with S17LPN. She stated that she was only aware of a reddened area to the left upper leg in the fold of the buttock area. She was not aware the resident had an open wound. An observation of a skin assessment was conducted on 11/15/2010 at 3:05 p.m. with S10 RN Wound Care Nurse. She assessed the wound as a Stage III pressure ulcer to the upper left leg at the left fold between the lower buttocks. She stated she was not aware of the Stage III pressure ulcer prior to the skin assessment today. An interview was held with S12LPN Charge Nurse for hall "B" and S10RN Wound Care Nurse on 11/15/2010 at 3:43 p.m. S12LPN Charge Nurse stated that the pressure ulcer was first discovered on 11/10/2010. S12LPN Charge Nurse stated that the night shift nurse discovered the ulcer and called the doctor and reported her findings and actions to her (S12) the morning of 11/11/2010. S12LPN Charge Nurse for hall "B" stated she talked about the findings in the morning report and reported the ulcer on the morning of 11/11/2010 to the S10RN Wound Care Nurse. S10RN Wound Care Nurse stated she was not informed in morning report of the change in Resident #12's skin. Review of the Nurse/Physician Communication Record dated 11/15/2010 at 3:15 p.m. stated that S10RN Wound Care Nurse was summoned to assess an area of concern on (L) upper leg in fold. Upon assessment she noted a Stage III pressure ulcer measuring 1.3 cm. X 1 cm. X 0.1 cm. wound bed that was yellow with slough present. Periwound was assessed to be red. New orders were noted. No odor was detected. She summoned the doctor to assess the area and received new orders to clean the wound with wound cleaner and dry. Further instructions Santyl ointment to the wound bed and cover with [MEDICATION NAME] dressing and change every 3 days. She was awaiting a call back from the family. She noted plans to continue to monitor and follow through with orders as ordered. An interview was held with S10RN Wound Care Nurse on 11/15/2010 at 3:45 p.m. She stated that she, the wound care nurse, should have been notified on 11/11/2010 when the wound was assessed to have worsened on the evening of 11/10/2010. An interview was held with S7DON on 11/16/2010 at 7:55 a.m. She stated she was not aware of a Stage III pressure ulcer on Resident #12 and she verified she should had HAVE been made aware of the pressure ulcer in the morning meeting. She also stated that in the morning meetings the department heads and charge nurses review issues that occurred with the residents including pressure sores. She further stated that there was no information on the notes from morning meeting that Resident #12's pressure sore was discussed. She went on to state that the nurses should document any problems with a resident including pressure sores in the 24 hour report communication book for the nurses. The 24 hour report communication book was brought to the morning meeting by the hall charge nurses and the information from the communication book was conveyed in the morning meetings. An interview was held with S10RN Wound Care Nurse on 11/16/10 at 8:15 a.m. She stated the procedure of reporting and treating pressure ulcers when found by a floor nurse was that she would be notified of the wound in the morning meeting and she would assess the wound as soon as possible. She would then call the doctor for treatment orders. She also stated that the nurse who spoke with the doctor on the evening of 11/10/10 could have gotten treatment orders for the wound when the physician called with the antibiotic order. An interview was conducted with S20Corporate Nurse on 11/17/10 at 4 p.m. She stated no documentation was found on the 24 hour communication book for the dates of 11/10/10 and 11/11/10. Review of the Wound Treatment Evaluation Record revealed an entry for 11/15/2010. Under the section labeled treatment and description of location, the wound was documented as cleaned with wound cleanser, dried, and Santyl applied to the wound bed. The wound was covered with a [MEDICATION NAME] dressing. The wound treatment was order for every 3 days. The wound for Resident #12 was assessed as yellow and the surrounding skin was red and no pain was assessed. Review of a Patient Note written by the Nurse Practitioner on 11/15/10 revealed a new wound assessed to the left buttocks. Review of physician's orders [REDACTED]. The order directed the nurse to apply Santyl ointment to wound bed and cover with a [MEDICATION NAME] dressing. The wound care order was ordered for every 3 days. An interview was held with S13CNA on 11/15/2010 at 3:37 p.m. regarding her observation of Resident #12's skin with incontinent care. She stated she thought that she first observed the wound being open on 11/14/10. Previously, she stated, before the wound opened up, it was just a reddened area, she had applied an antiseptic cream to the area while performing incontinence care. She stated that she assumed that the wound had been reported to the nurse already. She stated she had not reported the pressure ulcer to anyone or documented the pressure ulcer in the CNA Notes, or had the resident's nurse sign any documentation of the pressure ulcer. An interview was held with S9CNA Supervisor on 11/15/2010 at 3:41 p.m. regarding the procedure for CNAs to follow when a change in skin integrity was observed. She stated that any change in the integrity of a resident's skin was to be reported by the CNA to the resident's nurse as soon as observed. She also stated she should fill out a paper in the CNA Notes and have the nurse sign the note indicating she had been informed of the skin wound. S9CNA Supervisor stated that the resident's nurse would then report the development of a pressure ulcer to the Wound Care Nurse. She further stated the CNAs were inserviced recently on reporting all findings orally to the resident's nurse and in writing on the CNA Communication sheet. Review of a memo in the CNA Communication Book revealed CNAs are to report all findings with residents in their care; in writing on a CNA Communication Sheet and orally to that resident's nurse. The CNAs are to report any skin issues such as rashes, bruises, any and all skin tears, and other open areas on the resident's skin. The interview was continued with S9CNA Supervisor on 11/5/10 at 3:45 p.m. She stated she did not remember the date of the training the CNAs attended informing them to report all skin issues to the resident's nurse. Review of the Case Mix ADL Flow Record revealed no documented CNA skin checks on 11/4/2010, 11/5/2010, 11/7/2010, 11/8/2010, and 11/10/2010 through 11/17/2010. Review of the Physician order [REDACTED]. The previous tube feeding order was for [MEDICATION NAME] 1.5 at 45 cc/h for 22 hours/day. A review of the Diet Order and Communication slip for Resident #12 dated 11/2/2010 included instructions to change meals to breakfast, lunch, and dinner. The diet was to remain Pureed-pudding thick consistency. There were no written instructions regarding the order to change the tube feeding to [MEDICATION NAME] 1.5 at 45 cc/hr from 22 hours a day to only 6 p.m. to 6 a.m.(12 hours/day). An interview was held on 11/16/10 at 12:25 p.m. with S12LPN Charge Nurse for hall "B". She stated the order written on 11/02/10 was to change Resident #12's diet to oral feedings at breakfast, lunch, and dinner. The order also stated to change tube feeding to [MEDICATION NAME] 1.5 at 45 cc/hr from 6 p.m.-6 a.m. daily. She stated that she should have included the order for the tube feeding change on the Dietary Order Communication slip, but she had not included the tube feeding change information, only the oral feeding information. An interview was held on 11/16/10 at 12:35 p.m. with S16Dietician regarding the change of diet made on 11/02/10 for Resident #12. She stated that she was informed by the Dietary Manager of any changes to tube feeding orders. S16Dietician reviewed the Dietary Order Communication slip written for the diet change and she stated that due to the absence of the tube feeding order she did not assess Resident #12 on her visit to the facility on [DATE]. 11/08/2010 was the next visit by S16Dietician to the facility after the tube feeding was decreased by half the previous amount.. S16Dietician stated that the previous tube feeding was calculated to provide 100% of the resident's nutritional needs. She stated that the previous tube feeding order also provided the required amount of protein to promote optimal skin integrity. S16Dietician stated that the current order supplied less than 50% of the resident's caloric needs and 30% of her protein needs. Review of the interim care plan for Resident #12 revealed an intervention for Altered Nutrition/Hydration dated 10/18/2010. It was noted under problems and strengths that the resident was on [MEDICATION NAME] 1.5 at 45 cc/hr for 22 hours a day, due to an inability to consume adequate oral intake to maintain nutritional parameters. The goal was to have a gradual weight gain to 120 lbs. and maintain adequate nutritional status with the use of enteral feedings. Review of Resident #12's Meal Intake Record dated 11/14/10-11/20/10 revealed entries for intake for breakfast, lunch, and dinner ranged from 0 to 50 % intake at meal time. Review of Nutritional Progress Notes for Resident #12 dated 10/18/2010 revealed an entry written by S16Dietician that stated that with [MEDICATION NAME] 1.5 at 45 cc/hr the resident would receive 1485 kcal and 63 grams of protein and a total of 1502 ml of fluid a day. As previously stated in the interview with S16Dietician, she noted that this supplied the resident with adequate nutrition. Review of Nutritional Progress Notes for Resident #12 dated 11/16/2010 revealed an entry written by S16Dietician that stated the new order to decrease the tube feeding to [MEDICATION NAME] 1.5 at 45 ml/hr from 6 p.m. to 6 a.m. provided 810 kcal and 34 grams of protein and 1160ml of water. Due to poor appetite S16Dietician recommended to change tube feeding to [MEDICATION NAME] 1.5 at 55 cc/hr from 6 p.m.-6 a.m.. for 24 hours then increase the tube feeding by 10cc an hour every 24 hours to a goal rate of 80 cc/hour from 6 p.m.-6 a.m. The tube feeding at the goal rate would provide 1440 kcals, 61 grams of protein, and 1480 ml of water with medicine flushes. The tube feeding would then meet 100% of the estimated needs of the resident when the goal rate was reached of 80 cc/hour from 6 p.m. to 6 a.m. Resident # 20 Resident # 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] revealed the resident's cognitive status was severely impaired. She was totally dependent on staff for all of her care including transfers, position changes, incontinent care and Activities of Daily Living. Review of the record revealed a Skin Risk Evaluation and Plan of Care dated 07/20/10 with a Braden Scale Score of 14. A Braden Scale Score of 18 or below indicated at Risk for Skin breakdown. For a risk score less than 18 the directions were to complete the skin risk assessment evaluation and initiate the problem on the care plan. A review was done of the Nursing Evaluation dated 07/20/10, when the resident was admitted to the facility. It revealed the resident required assist of two staff for transfers, bed mobility, and toileting. The Braden Scale on the Nursing evaluation revealed a score of 14 which indicated the resident was At Risk for developing a pressure sore. The Skin Evaluation on the back of the form revealed the following: "dry scaly skin to heels & feet, end of toes c (with) dry scaly skin. Small scratch to (R) groin. No other breakdown or pressure areas noted." Review of the Weekly Skin Condition Evaluation form revealed documentation on 08/07/10 and 08/14/10 of "O (no) skin interruptions noted ". Review of the Nurses notes dated 08/20/10 and signed by S10RN Wound Care Nurse revealed "Resident found c (with) wound to (R) malleolus; yellow tissue serosangeous drainage painful to touch; ______NP (Nurse Practitioner) notified of new wound. Resident is [MEDICAL CONDITION] (R) [MEDICAL CONDITION]. New orders for Santyl & dry dressing daily ______for wound." There was no documentation in the nurse's note to indicate who informed the Wound Care Nurse of the wound to the resident's right outer ankle. Review of the Weekly Skin Condition Evaluation form revealed on 08/21/10 "(R) outer ankle area noted c (with) pressure ulcer found on 08/20/10." Review of the Wound Treatment Evaluation Record dated 08/20/10 revealed documentation of a Stage III with IV written over it that measured 1 x 0.8 x 0.1 with yellow wound bed, intact edges and dry. Review of the Physician Patient Note dated 07/26/10 revealed no problems with her skin. On 08/23/10 the physician documented under the skin area on the Patient Note "III-IV decubitus (R) heel." Review of the Care Plan revealed a Risk Factor/Problem dated 07/20/10 of "At Risk for skin breakdown related [MEDICAL CONDITION], A. Fib ([MEDICAL CONDITION] Fibrillation), DM (Diabetes Mellitus), Right [MEDICAL CONDITION], Depression [MEDICAL CONDITION](Hypertension)." Interventions under B. Mobility/Activity Deficit for Bed-bound Residents included use pillows to protect bony prominences; use pillows or devices that relieve pressure on heels; avoid positioning directly on hips; use lifting devices, turn sheets to reposition or transfer; reposition q (every) 2 h (hours) or PRN (as needed). and Screen by PT/OT (Physical Therapy/Occupational Therapy) for rehab potential. Review of the Physician order [REDACTED]. Review of the Physician Telephone Orders revealed an order dated 08/23/10 to "Apply Prevalon Boot to (R) leg & float both feet on pillows while in bed." On 11/17/10 at 1:30 p.m. an interview was held with S10RN Wound Care Nurse. She reported she had been employed at the facility for the past 2 weeks and didn't see the wound when it first developed. She said since she had been treating the wound it had improved. On 11/17/10 at 1:40 p.m. an interview was held with S34CNA Treatment Tech working with the wound care nurse. She reported she had been working at the facility for over a year as a Treatment Tech. She revealed the resident was admitted with no pressure wounds. She said the resident was a right [MEDICAL CONDITION] and slept with her right leg turned outward with the right ankle resting on the mattress. She reported the resident developed a small pressure ulcer on the outside of her right ankle. She said when it was found it was the size of a pencil eraser with yellow slough covering the wound bed. She reported the nurse received an order for [REDACTED]. On 11/17/10 at 2:00 p.m. an observation was made of the resident lying in bed with her right leg turned outward and the Prevalon boot in place. An observation was made of the pressure ulcer on the resident's right outer ankle with S10RN Wound Care Nurse and S34CNA Treatment Tech. The Prevalon Boot was removed from the right lower leg. The nurse removed the dressing from the wound. The wound bed was about 1 centimeter diameter and was bright pink with blood tinged drainage. She reported she had just completed wound care before the observation by cleaning the wound with wound cleanser and applying [MEDICATION NAME] ointment to the wound. After the observation she recovered the wound with a dressing. The Prevalon boot was reapplied. During the wound care no low air loss mattress overlay was observed on the resident's bed. Review of the Wound Treatment Evaluation Record dated 08/20/10 and 08/27/10 revealed the pressure ulcer was staged as a Stage IV. On 11/12/10 documentation revealed a Stage III to the right malleolus round, 1.4 x 1.3 x 0.1 cm. red with macerated ulcer edges and moderate serosangeous drainage. On 11/17/10 at 2:10 p.m. an interview with S28LPN, who worked with the resident on the morning shift, revealed the resident was unable to tell them when something was wrong. She said when the resident was in bed her right leg was paralyzed from the stroke and turned outward with the right ankle against the mattress. She reported she didn't work with the resident when the pressure ulcer was found in August. She said the resident currently had a boot to the right leg/foot to prevent pressure on the right outer ankle area. She said she had to be turned by staff because she was unable to turn herself. On 11/17/10 at 2:40 p.m. an interview was held with S8ADON. She reported the resident was admitted with no wounds and skin intact. She said she developed a pressure ulcer to her right outer ankle because when she was in bed her right leg turned out resulting in pressure on the right outer ankle. She reported all of the beds in the facility had pressure relieving mattresses. She said if a pressure area developed then a low air loss mattress would be placed on the bed. She said she didn't know why the resident didn't have one placed on her bed after she developed the pressure ulcer. She reported when the CNAs provided daily care for the residents they assessed the resident's skin and would report any changes to the nurse. She said the staff nurses did weekly skin assessments on all of the residents. She reported she didn't know why the resident's pressure ulcer was not found until it was a Stage III-IV. On 11/17/10 at 2:55 p.m. an interview with S29LPN Charge Nurse on "A" Hall, where the resident resided. She reported when the resident was admitted she had dry skin, but did not have any skin breakdowns. She said the resident's room was across from the nurse's station and the door to the room stayed open for observation. She reported the resident stayed in bed a lot when she was first admitted to the facility and couldn't talk. The Charge Nurse reported all residents had pressure relieving mattresses on their beds. She reported she didn't remember the resident ever having a low air loss overlay mattress on her bed because her pressure ulcer wasn't on her sacrum it was on her right ankle. She said a boot was ordered for the resident after the pressure ulcer was found and her foot was elevated. She reported when the resident was positioned on her right side she could still move enough so that her right leg was turned out with the boot lying on the mattress. On 11/17/10 at 3:00 p.m. an interview with S30CNA evening shift revealed she had worked at the facility for 2 months. She said the resident had the pressure ulcer on her right ankle when she started working with her. On 11/18/10 at 9:45 a.m. an interview was held with S32CNA who had worked at the facility for 1 ? years on the day shift. She reported the resident had the boot on her right foot because of the pressure ulcer when she started taking care of her. She said the resident could use her left leg to move her right leg when she was in the bed. On 11/18/10 at 10:50 a.m. another interview was held with S29LPN Charge Nurse on "A" Hall. She reported she was the charge nurse on the hall when the pressure ulcer was found on the resident. She said the wound care nurse who documented the wound assessment on 08/20/10 no longer worked at the facility. She reported she didn't know if someone told the wound care nurse about the wound or if she found it herself. She said the wound care nurses didn't routinely do skin assessments on the residents so someone must have told her. She reported sometimes the wound care nurses did do skin assessments of the whole facility, but she couldn't say for sure if that was how the wound care nurse had found the wound. She reviewed the nurse's notes for 08/19/10, 08/20/10, and 08/21/10. She reported the wound care nurse documented the wound and that she notified the physician. She said orders were received for wound care and the boot.

Based on record reviews, interviews, and facility policy, the facility failed to implement effective plans of action to correct identified deficiencies related to pressure ulcers (cross reference deficiencies at F272 and F314). This resulted in actual harm to Residents #12 and #20 when they developed avoidable pressure sores while residing at the facility (cross reference deficiencies at F272 and F314). Findings: Review of the information presented by the facility related to "Performance Improvement" revealed in part the following: There are many terms that are interchangeable for Performance Improvement (PI), for example Quality Assurance (QA), Quality Assessment and Assurance (QA&A), Continuous Quality Improvement (CQI), and Team Quality Management (TQM). The purpose of this committee, regardless of its name, is to develop and implement appropriate plans of action to correct identified quality deficiencies. All high risk areas should be monitored to identify if there are any potential or actual problems in that area. Monitoring is accomplished in a variety of ways; the following list is not all inclusive: -Audits that can be performed at regular intervals; such as chart audits, care plan audits, etc. -Tracking Logs that can help to establish trends, such as Pressure Ulcers, Weight Loss, Falls, etc. -Checklists that can help to identify problematic areas, such as water temperature, room temperature, fire drills, etc. The committee will implement the plan of action and "evaluate" its effectiveness until resolution has been achieved and maintained. An interview was held with S24RN Risk Manager on 11/18/10 at 10:45 a.m. She verified that she was the head of the QA committee. She said that pressure ulcers had been part of the facility's QA since March 2010. She said that the QA of pressure ulcers involved reviewing the weekly measurement tools from the Treatment Nurse at the monthly QA meeting to see if wounds were improving. When questioned about ensuring preventive measures were being carried out to prevent pressure ulcers, she said that the nurses did weekly body audits. She added that a few weeks ago that every resident in the facility had been checked for skin issues by the nurses which included the DON, ADON, and the previous treatment nurse. She identified the previous treatment nurse as S25LPN. An interview was held with S7DON on 11/18/10 at 11:05 a.m. She said that she received a weekly report from the treatment nurse about the number of wounds in the facility. She added that she had seen an increase in the number of wounds a few weeks ago. She said that at that time she, the ADON, and S25LPN had checked all residents in the facility for skin issues. She added that the checks involved head to toe body audits on all residents. She said the audits started on 11/2/10 and were completed on 11/5/10. She said that there was an inservice held for the nurses and CNAs on 11/4/10, and it was reviewed that skin issues were to be documented by the CNAs in the communication/jot book. She also said that she had started "T" time which involved an announcement that it was "T" time every 2 hours, and the residents were to be turned/repositioned. S7DON said she could not provide any documentation of the body audits performed by her, the ADON, and S25 LPN. According to her, there was not any monitoring/ follow up to ensure that the CNAs were documenting identified skin issues in the jot book. She also said that she could not provide evidence that the QA process involved any monitoring by the facility to ensure that turning/repositioning and other preventive measures were being carried out to prevent the development of avoidable pressure ulcers by residents in the facility.